Hutsonwood At Brazil
501 S Murphy Ave, Brazil, IN 47834 · Non profit - Corporation · 86 certified beds · (812) 446-2636 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- it has 1 actual-harm citation
- a high number of inspection citations overall (30) — 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 (1/5)
- 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 | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 3 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
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 1 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 | 14.5% | 11.0% | 15.4% | typical |
| Long-stay residents who lose too much weight | 0.5% | 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 | 0.4% | 1.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 10.1% | 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 | 2.9% | 3.9% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 9.9% | 11.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 29.8% | 23.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 85.9% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.2% | 3.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 23.5% | 23.3% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 28.9% | 13.6% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 3.0% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 10.9% | 79.0% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 24.4% | 22.2% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 11.4% | 10.8% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.63 | 1.61 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.91 | 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.
51.3% 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 102 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 59.1% 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 44 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: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.
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 | 51.3%CMS range 41.0–61.4 | 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 | 13.4%CMS range 8.9–18.3 | 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 | 59.1% | 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 | 40.9% | 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 | 56.8% | 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 | 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 | 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 | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.7% | 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 | 8.2%CMS range 5.2–12.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.12 | 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 86 beds and averages 73.5 residents a day — about 85% occupied, or roughly 12 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 3.16 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 1.99 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 2.84 hrs/resident/day on weekends vs 3.29 on weekdays — 14% thinner on weekends. RN hours go from 0.65 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 50% 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.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · Gcited before2026-01-12 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide range of motion or appropriate interventions for 2 of 2 residents reviewed for range of motion (Residents 69 and 12) resulting in actual harm when a cognitively impaired dependent resident developed contractures of the left hand and arm (Resident 69). Findings include:1. On 1/5/26 at 10:00 a.m., during initial observation, Resident 69 was sitting in a high back wheelchair in the lounge area. Observed the left arm bent upwards at the elbow and the left hand contracted. Nails were pressed into the palm of her hand. No anticontracture devices observed on hand or arm. On 1/6/26 at 10:29 a.m., resident observed sitting in wheelchair in lounge area and noted to have contracture of the left hand and lower left arm. No anticontracture device observed in place. On 1/6/26 at 9:34 a.m., during an interview Licensed Practical Nurse (LPN) (10) indicated Resident 69 walked with therapy for a time but acted like she was afraid and they…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-05-11 · tag F0880 — failed to prevent and control infections — patternProvide 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 follow infection control measures when handling clothing and waste for prevention of transmission of multidrug-resistant organisms (MDRO) for 4 of 4 residents reviewed for infection control. (Residents B, C, D, and E). This deficient practice had the potential to affect 75 of the 75 residents residing in the facility.Findings include:During a random observation on 5/11/26 at 11:05 a.m., Receptionist 1 was observed walking out of Resident C and Resident D's room, wearing gloves and holding a pile of clothing in her hands. The clothing was not in a bag and would brush the front of her shirt as she walked. During the observation, Receptionist 1 indicated the clothing was some dirty clothes she was taking to the soiled utility. She indicated she could not find a bag to place them in, so she just donned gloves and was carrying them.1. During an interview on 5/11/26 at 11:50 a.m., Resident C indicated he had not observed staff putting on a gown when they entered his room to care for him. The staff do perform…
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 · F2026-01-12 · tag F0802 — failed to prepare enough nourishing food — widespreadProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure the dietary staff were trained and competent in infection control measures to prevent food borne illness during 4 observations of the dietary department. The deficient practice had the potential to affect 77 of 77 residents who received food and/or drinks from the kitchen. Findings include: On 1/5/26 at 10:45 a.m., during a kitchen observation with the Dietary Manager, the dishwasher temperature was not within the recommended range for sanitation. Review of the temperature logs indicated the logs were incorrect. The Dietary Manager confirmed the documentation had been recorded inaccurately by the employee. On 1/5/26 at 11:00 a.m., observed the Dietary Manager wash her hands and dried hands on rolled damp paper towels that were on top of the counter in the food prep area. She indicated the dispenser batteries were low, and the paper towel dispenser was not working. The Dietary Manager acknowledged the paper towels were not sanitary. On 1/5/26 at 12:38 p.m., during a follow up in the dietary department…
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 before2026-01-12 · 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
A. Based on observations, record review, and interview, the facility failed to ensure frozen foods were dated prior to use and failed to ensure dishwasher was sanitizing dishes and utensils at the recommended temperatures for sanitation during 6 dietary observations. This deficient practice had the potential to affect 77 of 77 residents who receive food and drinks from the kitchen. B. Based on observation, interview, and record review, the facility failed to ensure ice was distributed in a safe and sanitary manner during 1 of 1 lunch meal service observations. This deficient practice had the potential to affect all residents that were being served in the main dining room on 1/5/26. Findings include: A. On 1/5/26 at 10:45 a.m., during a kitchen observation with the Dietary Manager the following was noted. The wash temperature of the dishwasher reached 140 degrees. The rinse temperature reached 162 degrees. The Dietary manager indicated the dishwasher was not at the appropriate temperature. Review of the temperature logs for breakfast on 1/5/26 indicated the temperature had been…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-12 · 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
Based on observation, interview, and record review, the facility failed to ensure that resident personal information was protected from exposure, during 1 of 2 medication administration observations (Residents 34, 78, and 8). Findings include:During observation of medication administration with Licensed Practical Nurse (LPN) 8, on 1/8/26, the following was observed: a. On 1/8/26 at 8:28 a.m., LPN 8 set up the medications to administer to Resident 34. She was observed to use the desk computer to rectify the medications. At the same time, she indicated she was using the desk computer at the nurse's station because the laptop on the medication cart would not stay charged. She left the nurse's station to administer the medications and left the resident's personal information exposed on the computer screen without closing or covering the screen. b. On 1/8/26 at 8:41 a.m., LPN 8 set up the medications to administer to Resident 78. She was observed to use the desk computer to rectify the medications. She left the nurse's station to administer the medications and left the resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to initiate or revise interventions to prevent falls for 1 of 1 residents reviewed for accidents (Resident 12). Findings include:On 1/5/26 at 2:00 p.m., during an initial observation, Resident 12 was observed sleeping in bed. The resident was lying on her back with her head hyperextended. The bed was in the low position. A padded mat was on the floor next to the left side of the bed. The call light was lying on the foot of the bed. On 1/9/26 at 10:00 a.m., the medical record of Resident 12 was reviewed. The most recent admission to the facility was on 9/25/25. admission diagnosis included, but was not limited to, fracture of right femur (bone fracture of the right hip), pain in right hip and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). A significant change Minimum Data Set (MDS) assessment, dated 10/1/25, indicated the resident was cognitively impaired and was dependent upon staff for all daily care needs…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure a resident had physician's order and a care plan for an indwelling urinary catheter (a thin, flexible tube left inside the bladder, typically through the urethra, to continuously drain urine into an external collection bag), failed to ensure the catheter's external urine collection bag (catheter bag) and tubing were prevented from contact with the floor, and failed to ensure the catheter bag was maintained in a dignified manner, for 1 of 1 resident observed for urinary catheter (Resident 21). Findings include: During an initial observation of Resident 21, on 1/6/26 at 9:14 a.m., the resident's catheter bag was observed in contact with the floor. The resident was sitting in her wheelchair next to her bed. During a random observation, on 1/7/26 at 9:04 a.m., the resident was observed in her room in her wheelchair. The resident's catheter tubing was in contact with the floor. During a random observation, on 1/7/26 at 1:06 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 · D2026-01-12 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to obtain a resident's medications in a timely manner after their admission to the facility for 1 of 6 residents reviewed for pharmaceutical services (Resident B). Findings include:Resident B's record was reviewed on 1/9/26 at 10:14 a.m. Census information indicated the resident was admitted to the facility on [DATE]. A Medication Administration Record (MAR), dated December 2025, included the following information. -A physician's order, dated 12/19/25, indicated administer ascorbic acid (supplement) 250 milligrams (mg) by mouth daily for muscle wasting. The medication was not administered, on 12/19/25, related to pharmacy delivery tonight. The medication was not administered, on 12/27/25, 12/28/25, and 12/31/25, related to awaiting from pharmacy. The MAR lacked documentation the physician or the pharmacy were contacted regarding the missed administrations. -A physician's order, dated 12/19/25, administer enoxaparin (blood thinner) 30 mg/0.3 milliliters…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-12 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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 record review and interview, the facility failed to ensure documented physician rationale for a declination of a pharmacy recommendation and failed to ensure a pharmacy recommendation was addressed in a timely manner for 2 of 5 residents reviewed for unnecessary medications (Residents 11 and 13). Findings include:1. Resident 11 record was reviewed on 1/6/26 at 3:46 p.m. The profile indicated the resident's diagnoses included, but were not limited to, diabetes mellitus (a group of metabolic diseases marked by consistently high blood sugar (glucose) due to the body's inability to produce or properly use insulin), overactive bladder (a common condition marked by a sudden, uncontrollable urge to urinate, often leading to frequent bathroom trips, and chronic kidney disease stage 3 (your kidneys have moderate damage, filtering blood less effectively, leading to waste buildup and potential complications like high blood pressure, anemia (low iron), and fatigue). Facility census information indicated Resident 11…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-12 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to assess a resident for pain and administered narcotic medication without documentation of pain symptoms for 1 of 5 residents reviewed for unnecessary medications (Resident 13). Findings include:On 1/5/26 at 11:00 a.m., observed Resident 13 sleeping in bed. He was not restless and was sleeping soundly. No outward signs of pain observed. On 1/5/26 at 12:30 p.m., observed resident sitting in a high back wheelchair during the noon meal service. Resident was relaxed and no visual indicators of pain noted. The resident was relaxed and looked comfortable On 1/7/26 at 10:40 a.m., the medical record of Resident 13 was reviewed. The resident was admitted to the facility on [DATE]. admission diagnosis included, but was not limited to, hemiplegia (a loss of strength in the arm, leg, and sometimes face on one side of the body) and hemiparesis (a relatively mild loss of strength) following cerebral infarction (stroke), dementia (the loss of 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 · Dcited before2026-01-12 · 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, record review, and interview, the facility failed to ensure it was free of a medication error rate of greater than 5 percent for 3 of 7 residents observed during the medication pass. There were 26 opportunities for errors observed with 3 medication errors, resulting in a medication error rate of 11.54 percent (Residents 34, 78, and 8). Findings include:1a. On 1/8/26 at 8:28 a.m., Licensed Practical Nurse (LPN) 8 administered medications to Resident 34. The medications included, but were not limited to, fluticasone propionate (Flonase) 50 micrograms (mcg) nasal spray (a corticosteroid medication used to relieve allergy symptoms) 1 spray to each nostril two times daily. The LPN shook the nasal spray container and placed the tip into the resident's left nostril and sprayed. She then placed the tip of the nasal spray into the resident's right nostril and sprayed it. The LPN failed to instruct the resident to pinch off his opposite nostril as she administered the nasal spray. An active physician's order, reconciled on 1/9/26 at 1:57 p.m., indicated to administer 1…
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 · Dcited before2026-01-12 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure multi-use vials of medication had open dates documented, for 1 of 3 medication carts reviewed. Findings include: On 1/9/26 at 10:46 a.m., an observation of medication cart 1 of the back hall indicated the following a. An open bottle of nasal spray for Resident 71 lacked documentation of an open date. Resident 71's record was reviewed on 1/9/26 at 11:15 a.m. The profile indicated the residents' diagnoses included, but were not limited to, nasal congestion (when the tissues lining the nasal passages are swollen and inflamed, making it hard to breathe through the nose, often accompanied by runny nose). A physician's order, dated 1/6/26, indicated to administer 2 sprays of Vicks [NAME] 12-hour non-aerosol nasal spray (a nasal decongestant that shrinks swollen blood vessels in your nose), 2 sprays in each nostril, two times a day. b. An open bottle of fluticasone propionate nasal spray (a type of medication used to treat and prevent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-12 · 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 A. Based on observation, interview, and record review, the facility failed to ensure a resident's indwelling urinary catheter (a thin, flexible tube left inside the bladder, typically through the urethra, to continuously drain urine into an external collection bag), external urine collection bag (catheter bag) and tubing were prevented from contact with the floor, for 1 of 1 resident observed for urinary catheter (Resident 21). B. Based on observation, interview, and record review, the facility failed to ensure proper hand hygiene during medication administration for 1 of 2 medication administration observations. Findings include:A. During an initial observation of Resident 21, on 1/6/26 at 9:14 a.m., the resident's catheter bag was observed in contact with the floor. The resident was sitting in her wheelchair next to her bed. During a random observation, on 1/7/26 at 9:04 a.m., the resident was observed in her room in her wheelchair. The resident's catheter tubing was in contact with the floor. Resident 2's…
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 · D2025-08-14 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to transport a resident to a scheduled surgical procedure for 1 of 3 resident reviewed for quality of care. (Resident B)Findings include:A clinical record review for Resident B was completed on 8/14/25 at 10:00 a.m. Diagnoses included urinary tract infection, Parkinson's disease, obstructive and reflux uropathy, and dementia. A physician's order, dated 8/10/25, indicated resident was to have nothing by mouth after midnight due to a scheduled surgery on the morning of 8/11/25. Administer morning medications with a small sip of water. The order had a discontinued date of 8/3/25 due to resident being out of the facility at an acute care hospital.A nursing progress note, dated 8/3/25, unknown time, indicated resident B reported not feeling well. She was short of breath and warm to touch. Her heart rate was elevated at 113 beats per minute. The physician was notified and the resident was transferred via ambulance to an acute care hospital.A nursing progress…
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 · D2025-02-12 · 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 observation, record review, and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for 1 of 9 residents' MDS assessments reviewed (Resident E). Findings include: During an observation on 2/10/25 at 2:00 p.m., Resident E was sitting up in her wheelchair with a tray table attached to the right side of her wheelchair. Her right arm was resting on the table. Resident E's record was reviewed on 2/12/25 at 9:42 a.m. An admission MDS assessment, dated 12/9/24, indicated the resident had severe cognitive impairment and no functional limitation in range of motion (ROM) to the upper or lower extremities. Diagnoses on the resident's profile included, but were not limited to, hemiplegia (paralysis or weakness on one side of the body) unspecified affecting right dominant side. An admission observation, dated 12/3/24, indicated the resident had impairment on one side of the upper extremities. A Physician's Progress Note, dated 12/4/24, indicated the resident's assessment showed right sided hemiparesis (weakness or paralysis on one side 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 · Dcited before2025-02-12 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to ensure limitations in range of motion were assessed, treated, and required interventions communicated to staff effectively for 3 of 3 residents reviewed for limitations in range of motion (Residents B, E, and F). Findings include: 1. During an interview, on 2/10/25 at 12:00 p.m., Resident B's family member indicated the resident had splints for her hands that she needed to prevent contractures (permanent or prolonged shortening of muscles, tendons, ligaments, or skin that restricts range of motion and can lead to deformities). The splints arrived to the facility with the resident at admission and were kept beside. The splints were not used until 12/14/24. The family member indicated they asked staff about using the splints, but the staff were not aware of them. On 12/13/24, therapy put the splints on the resident and indicated if there was no redness or soreness they would be used at night. On 12/14/24, a regimen for the hand splints 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 · D2024-10-22 · 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
Based on observation, interview, and record review, the facility failed to ensure contracted staff completed a resident assessment and vital signs in privacy for 1 of 1 resident reviewed for privacy (Resident 26). Findings include: During the meal service on the memory care unit, on 10/16/24 at 12:04 p.m., Resident 26 was sitting in her Broda chair (a wheelchair or seating device designed to provide comfort and support for long-term patients) at a table waiting for lunch to be served. A contracted hospice nurse entered the dining area where Resident 26 was sitting. Hospice Nurse 23 obtained vital signs on Resident 26. The nurse obtained a temporal (forehead) temperature, blood pressure (using a wrist cuff), pulse oximeter reading, heart rate, and a circumference of her right arm (using a tape measure). The hospice nurse leaned in next to the resident's ear to ask her some questions about how she was feeling. There were several residents sitting at the table during this time along with the licensed practical nurse and certified nurses' aide. During an interview, on 10/16/24 at 12:09…
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 · D2024-10-22 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to ensure a call light device was within reach for 1 of 16 residents observed for call lights (Resident 7). Findings include: On 10/17/24 at 10:08 a.m., observed Resident 7 in his room, sitting in a Broda chair (a wheelchair or seating device designed to provide comfort and support for long-term patients) facing the window. He was leaning to the right side of the chair, the left side of his face was directly in the sunlight, the room temperature was hot, and his cheeks were reddened. Two button-press call lights were observed to be on the beds, not within reach of the resident. On 10/17/24 at 10:13 a.m., requested assistance from Certified Nursing Assistant (CNA) 5, upon entering Resident 7's room, she indicated the room was hot and that it looked like the resident was leaning to get out of the sunlight. She indicated the resident did not have his call light, but he did not use it. Before leaving the room, she provided him with a button-press call light. On 10/21/24 at 1:34 p.m., observed Resident 7 resting 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 · D2024-10-22 · 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 record reviews and interviews, the facility failed to ensure a pharmacy recommendation was addressed for 1 of 5 residents reviewed for unnecessary medications (Resident 32). Findings include: On 10/21/24 at 9:27 a.m., pharmacy recommendations were reviewed for Resident 32. A recommendation, printed 10/23/23, indicated that the resident was receiving Zoloft (medication used to treat depression, anxiety, and other disorders) 50 milligrams (mg) daily, and asked the physician to determine if a gradual dose reduction may be attempted. The physician signed and dated the form on 10/25/23 indicating to decrease the Zoloft to 25 mg daily. A recommendation, printed 12/17/23, notified the physician to investigate the recommendation made on 10/23/23 for the gradual dose reduction because their record indicated that the Zoloft would be decreased to 25 mg, however a dose reduction had not been ordered. A record review was conducted on 10/21/24 at 10:12 a.m. Resident 32's diagnoses included, but were not limited to, major depressive disorder (depressed mood or loss of interest 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 · Dcited before2024-10-22 · 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, record review, and interview, the facility failed to ensure proper handling of oral medications during the medication administration pass and failed to ensure medication was administered according to manufacture guidelines resulting in a medication error rate of greater than 5 percent for 2 of 4 residents reviewed for medication administration (Residents 10 and 217). Findings Include: On 10/22/24 at 7:10 a.m., during routine medication administration observation, Registered Nurse 18 placed medications for Resident 10 into her bare hand then placed the medications in a medication cup, and then administered medications to the resdient. The RN prepared Novolog insulin with an insulin pen (a pre-filled pen device filled with insulin. Doses are provided in one-unit increments for insulin medicines) The nurse failed to first prime the pen according to manufacture guidelines prior to administration of the insulin to Resident 10. Observed the nurse administer Arnuity Ellipta 200 mcg (micrograms) 1 inhalation, (an inhaled corticosteroid (ICS) medicine. ICS medicines…
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 before2024-10-22 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure a multi-dose insulin vial was discarded within 28 days of use and insulin pens containing multiple doses of insulin were dated appropriately and discarded within 28 days of use for 2 of 2 medication carts observed. Findings include: On 10/21/24 at 10:30 a.m. an observation of medication cart 1 found a multidose vial of Amaolg insulin, prescribed for Resident 2 was filled on 8/13/24. No date opened was observed on the label or the bottle. On 10/21/24 at 10:35 a.m., an observation of medication cart 2 found 2 Lantus insulin pens prescribed for Resident 20 dated as opened on 9/1/24 and 9/15/24. A Basaglar insulin pen prescribed for Resident 6 did not have a date opened on the pen. The prescription label indicated it was opened on 9/1/24 On 10/21/24 at 10:35 a.m., during an interview with Licensed Practical Nurse (LPN) 12 the nurse indicated. Once opened an insulin vial and pen are good for 30 days. On 10/21/23 at 10:54 a.m., during an interview with the Director of Nursing (DON) she indicated insulin pens expired 28 days…
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 before2024-10-22 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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, and record review, the facility failed to ensure snacks were served in a sanitary manner for 1 of 1 random snack distribution observations. Findings include: During a random snack distribution observation, on 10/21/24 at 10:03 a.m., Activity Assistant 8 was on the memory care unit and was removing fudge round cream cookies from its plastic packaging and removing the snack with her bare hands and handed cookies to 7 different residents. The activity assistant was not observed using gloves or hand sanitizer during the observation. During a second observation, on 10/21/24 at 10:05 a.m., Certified Nurse's Assistant (CNA) 9 went into the nutrition room (kitchenette area) and got some milk for a male resident and she also removed a fudge round cream cookie from its plastic packing with bare hands and handed it to the male resident. She then touched the resident's shoulder and headed down the hallway. The CNA was not observed using gloves or hand sanitizer during the observation. During an interview, on 10/21/24 at 10:13 a.m., CNA 10…
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 · D2024-10-22 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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 record review the facility failed to document insulin administration for 1 of 5 residents reviewed for medication administration (Resident 23). Findings include: On 10/21/24 at 9:36 a.m., the medical record of Resident 23 was reviewed. The resident was admitted to the facility on [DATE]. Admitting diagnosis included but were not limited to, chronic obstructive pulmonary disease (COPD) (a group of diseases that cause airflow blockage and breathing-related problems), type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high), with diabetic neuropathy (a type of nerve damage that can occur if you have diabetes), Gastroesophageal reflux disease (GERD) (a common condition in which the stomach contents move up into the esophagus). Physician Order, dated 3/11/24, indicated to administer Lispro Insulin Per Sliding Scale. If Blood Sugar is less than 60, call MD (Medical Doctor). If Blood Sugar is 180 to 220, give 2 Units. If Blood Sugar is 221 to 260, give 4…
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 before2024-10-22 · 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 proper handwashing was completed during for resident care, and failed to ensure proper handling of the glucometer meter (small portable machine that's used to measure how much glucose [type of sugar] is in the blood) during medication administration for 2 of 2 residents reviewed during medication administration observation (Residents 10 and 217). Findings include: On 10/21/24 at 11:36 a.m., during routine handwashing observation, Licensed Practical Nurse (LPN)12 washed her hands and turned off the faucet with her bare hands. Then dried her hands with a paper towel. On 10/21/24 at 11:36 a.m., during medication administration, LPN 12 obtained the blood sugar reading of Resident 31 using a glucometer meter. The nurse wiped the machine with Sani wipe cleanser wipe (a disposable wipe used to disinfect and clean non-porous surfaces and medical devices) and set the glucometer aside on a paper towel. The nurse failed to keep the device wet for 2 minutes as per the manufacture guidelines. On 10/22/24 at 7:10…
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 · D2024-08-27 · 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, record review, and interview, the facility failed to ensure wound care was provided for 2 of 2 residents reviewed for wound care (Residents S and C). Findings include: 1. On 8/26/24 at 2:51 p.m., observed the Resident S lying in bed with left leg propped on pillow. The resident was alert and oriented. The left foot was wrapped in Kling gauze. A date of application was not on the dressing. The resident indicated the dressing to the left foot had not been changed at the time of the observation and had not been changed over the previous weekend. The resident indicated when the nurse changed the dressing they would date it. On 8/26/24 at 3:00 p.m., the medical record of Resident S was reviewed. Diagnoses included but were not limited to, complications of amputation stump left foot, acquired absence of left foot part of foot, type 2 diabetes mellitus with hyperglycemia (a disease that occurs when your blood glucose, also called blood sugar, is too high), chronic kidney disease, stage 4 (a severe stage of kidney disease where the kidneys are moderately to severely…
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 before2023-09-22 · 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 facility failed to ensure staff sanitized their hands appropriately, the deep fryer and stove were cleaned, and a cup was not stored in the flour canister, for 2 of 2 kitchen observations and the facility failed to ensure hand hygiene was completed and safe handling of food during 2 of 2 meal observations. Findings include: 1. On 9/17/23 at 10:26 a.m., the Dietary Director (DD) washed her hands for less than 10 seconds, then began the initial tour of the kitchen with the following concerns observed: The deep fryer was observed with a large amount of food debris floating in the oil with food debris on top and down the sides of the deep fryer. The stove/oven had food debris and oil buildup on the top, down the sides, and in the grease trap of the appliance. The inside of the oven was soiled with food debris and grease running down the inside of the oven door. A Styrofoam cup was observed in the flour canister. On 9/17/23 at 10:34 a.m., the DD indicated when washing her hands, she should have scrubbed her hands with soap for 20…
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 before2023-09-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was free from accidents for 1 of 2 residents reviewed for accidents (Resident 14). Finding includes: During an interview, on 09/18/23 at 9:50 a.m., Resident 14 indicated she was in the shower room sitting on the toilet when staff had left the shower room to obtain supplies needed for her shower. The resident indicated she attempted to transfer herself from the toilet to her wheelchair and she fell and hit her head on the floor in the shower room. She had to go to the hospital for treatment. Resident 14's record was reviewed on 9/19/23 at 10:23 a.m. The profile indicated the resident's diagnoses included, but were not limited to traumatic subarachnoid hemorrhage without loss of consciousness (the sudden onset of a severe headache, often accompanied with nausea, vomiting, and a loss of consciousness caused by traumatic brain injury or ruptured brain aneurysm [a bulge in a week area of blood vessel in or around your brain]), type II…
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 before2023-09-22 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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 pharmacy recommendations were completed for 1 of 5 residents reviewed for unnecessary medications (Resident 34). Finding includes: On 9/20/23 at 8:54 a.m., Resident 34's record was reviewed, with diagnoses included, but not limited to, congenital malformation of heart (abnormality in the heart that develops before birth), cardiomyopathy (chronic disease of the heart muscle), and heart failure (chronic, progressive condition in which the heart muscle is unable to pump blood as well as it should). A pharmacy consultation report, dated 11/14/22, recommended Resident 34 to have blood lab work of a basic metabolic panel (BMP) (blood test to assess several important aspects and the general physical health of the blood) and blood lab work of a vitamin D level (blood test to assess the level of vitamin D in the blood to ensure the muscles, nerves, and immune system are working normally). The pharmacy consultation report was blank without a physician's response. On 9/20/23 at 10:00 a.m., the Director of Nursing (DON)…
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 before2023-09-22 · 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, record review, and interview, the facility failed to ensure fast-acting insulin medication was administered within a timely manner of meal service for 2 of 2 residents reviewed for significant medication error resulting in a medication error rate of 6.25 percent (Resident's 7 and 23). Findings include: During the survey, medication administration was observed. There were 2 errors observed during the 32 opportunities for errors observed resulting in a 6.25% error rate. 1. On 9/20/23 at 11:10 a.m., Licensed Practical Nurse (LPN) 10 was observed obtaining a blood glucose (the main sugar found in your blood) reading for Resident 7. The resident's blood glucose reading measured 245. On 9/20/23 at 11:18 a.m., LPN 10 was observed to administer a total of 15 units of Novolog (a rapid-acting insulin that helps lower mealtime blood sugar spikes in adults and children with diabetes) into Resident 7's abdomen. On 9/20/23 at 11:40 a.m., the resident was observed sitting in the activity lounge area participating in a trivia activity. On 9/20/23 at 11:53 a.m., staff 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 · D2023-09-22 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 appropriate temperature and palatability of food served for 2 of 24 residents reviewed for dietary services (Residents 23, and 52), 1 of 1 resident council meeting reviewed for dietary concerns, and 1 of 1 test tray reviewed for temperature and palatability. Findings include: During an interview, on 9/18/23 at 9:32 a.m., Resident 23 indicated, she ate breakfast and supper in her room and ate lunch in the main dining room, and the food, at times, was cold. During an interview, on 9/18/23 9:36 a.m., Resident 52 indicated, she ate meals in her room and the food was often cold, when her meal came to her room. A group resident council meeting from 7/12/23, indicated the residents had a concern for the dietary department that the meat was too tough. The kitchen had provided education to the dietary staff regarding tough meat that was served to the residents. On 9/20/23 at 12:57 p.m., test tray food temperatures were measured by the Dietary Director. The roast beef temperature measured at 126 degrees Fahrenheit, 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.
“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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PUTNAM COUNTY HOSPITAL | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 06/01/2015 |
| BRAY, ARNOLD | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 09/01/2012 |
| FRY, JANICE | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 09/01/2012 |
| HEADLEY, MATTHEW | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 09/01/2012 |
| LANDRY, KEITH | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 09/01/2020 |
| LEWIS, KATRINA | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 12/21/2022 |
| UNDERWOOD, WENDELL | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 05/20/2024 |
| WEATHERFORD, DENNIS | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | — | since 09/18/2012 |
| WOOD, MARK | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 08/05/2024 |
| SILLERY, DEBRA | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/03/2026 |
| ELC OF BRAZIL, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/19/2025 |
| HHSS MANAGEMENT, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2020 |
| BERRY, MANOJ | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/25/2022 |
| MENDOZA, CAMILLO | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2017 |
| BARACH, ANDREA | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 09/19/2025 |
| CORBITT, JO ANNE | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 09/19/2025 |
| LOUDERMILK, CHRISTOPHER | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 09/19/2025 |
| BRAZIL FACILITY COMPANY LLC | Organization | ADP OF THE SNF | — | since 11/06/2012 |
| HOOSIER CARE PROPERTIES INC | Organization | ADP OF THE SNF | — | since 06/01/2015 |
| HOOSIER WEST LEASING COMPANY LLC | Organization | ADP OF THE SNF | — | since 11/06/2012 |
CMS files one row per role, so the 34 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted.
6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $841K paid to related parties — landlords or management companies under common ownership — equal to about 12% 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 155503. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-12, 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.