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George Ade Memorial Health Care Center

3623 East State Rd 16, Brook, IN 47922 · Government - County · 70 certified beds · (219) 275-2531 Medicare & Medicaid certified

Call the home — (219) 275-2531 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (26) — 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)

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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 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

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
420 E Main St · (219) 275-2521 · Call to confirm hours
Pharmacy
303 N 7th St · (219) 474-5464 · Call to confirm hours
Grocery
3375 S County Road 100 E · (219) 863-6553 · Call to confirm hours
Park
3300 N 050 · Typically dawn to dusk
Place of worship
5400 E County Road 1000 S

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 3 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 improved from 2 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased20.8%11.0%15.4%worse
Long-stay residents who lose too much weight2.0%5.5%5.4%better
Long-stay residents with a catheter left in their bladder0.8%0.4%0.9%typical
Long-stay residents with a urinary tract infection10.0%1.1%2.0%worse
Long-stay residents with depressive symptoms1.0%25.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury5.6%3.9%3.3%worse
Long-stay residents whose ability to walk worsened19.6%11.9%16.1%worse
Long-stay residents on antianxiety or hypnotic medication18.9%23.5%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%95.4%95.3%typical
Long-stay residents with pressure ulcers2.3%3.6%4.7%better
Long-stay residents with worsening bladder/bowel control18.2%23.3%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table11.7%13.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%79.0%79.4%better
Short-stay residents rehospitalized after admission12.3%22.2%22.6%better
Short-stay residents with an outpatient ER visit11.4%10.8%12.0%typical
Long-stay hospitalizations per 1,000 resident days0.801.611.67better
Long-stay outpatient ER visits per 1,000 resident days1.531.441.80better

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.

47.6% 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 41 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

47.6%U.S. median 51.5%
Got home and stayed home
12.9%U.S. median 10.7%
Went back to hospital
69.2%U.S. median 56.6%
Met the expected recovery
0.17U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 69.2% 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 26 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 0.17 therapist hours per resident per day in 2026Q1 — more than 15% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF47.6%CMS range 37.0–60.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.9%CMS range 9.7–17.510.7%Oct 2022–Sep 2024no 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 discharge69.2%56.6%Oct 2024–Sep 2025CMS 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 discharge61.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge50.0%50.0%Oct 2024–Sep 2025CMS 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 identified100.0%98.7%Oct 2024–Sep 2025CMS 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 settingnot 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.5%CMS range 3.6–12.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.951.02Oct 2022–Sep 2024CMS 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

0.35
RN hours/ resident / day
0.99
LPN hours/ resident / day
2.19
Aide hours/ resident / day
3.53
Total nurse hours/ resident / day
0.28
RN hoursweekends
30.8%
Total nursing turnover
16.7%
RN turnover

How full it usually is: this home is certified for 70 beds and averages 61.1 residents a day — about 87% occupied, or roughly 9 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 3.53 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.19 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.20 hrs/resident/day on weekends vs 3.66 on weekdays — 13% thinner on weekends. RN hours go from 0.37 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 31% is below 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

9
deficiencies at the latest standard inspection (2026-03-06)
4
at the previous standard inspection (2025-01-24)

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.

ABCDEFGHIJKL

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.

26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.

  • Actual harm · Gcited before2025-11-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 record review and interview, the facility failed to ensure a resident received adequate supervision and assistance to prevent accidents, related to one staff member (CNA 1) assisting a resident with a shower who was care planned for two staff assistance for activities of daily living (ADL's) resulting in the resident falling in the shower and receiving an abrasion to the right knee and a laceration to the right eyebrow that required four sutures. The resident also had a decline in normal functioning related to ambulation after the fall and was diagnosed eight days later with a fractured right hip for 1 of 3 residents reviewed for accidents and supervision. (Resident D)Finding includes: Resident D's record was reviewed on 11/12/25 at 1:18 p.m. The diagnoses included, but were not limited to, right hip fracture, Alzheimer's disease, dementia, and moderate intellectual disabilities.A Care Plan, dated 7/16/25, indicated a self-care deficit was present related to the impaired cognitive status. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-06 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor 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, record review, and interview, the facility failed to ensure a resident's dignity was maintained related to an uncovered urinary catheter bag and a resident's choice was honored for bathing for 2 of 2 residents reviewed for dignity. (Residents G and 57)Findings include: 1.On 3/3/26 at 9:53 a.m. Resident G was observed lying in bed. A urinary catheter bag was hanging from the side of the bed with visible urine in the bag. There was no cover over the bag, and the bag was visible from the hallway. On 3/3/26 at 2:47 p.m. Resident G was observed lying in bed. A urinary catheter bag was hanging from the side of the bed with visible urine in the bag. There was no cover over the bag, and the bag was visible from the hallway. On 3/4/26 at 11:23 a.m. Resident G was observed lying in bed. A urinary catheter bag was hanging from the side of the bed with visible urine in the bag. There was no cover over the bag, and the bag was visible from the hallway. Record review for Resident G was completed on 3/4/26 at 2:23 p.m. Diagnoses included, but were not limited to, obstructive…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-06 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) comprehensive assessment was accurately completed related to a Wanderguard alarm (wearable device that alarms when approaching a restricted area) not documented for a resident with history of wandering for 1 of 21 MDS assessments reviewed. (Resident 37) Finding includes:The record for Resident 37 was reviewed on 3/3/26 at 8:59 a.m. Diagnoses included, but were not limited to, dementia and Parkinson's disease. The Quarterly Minimum Data Set (MDS) assessment, dated 1/26/26, indicated the resident had moderate cognitive impairment, required partial to moderate assistance with shower, personal hygiene, and taking footwear on and off. The alarm assessment was marked as 0 indicating not used. The Physician's Order, dated 12/15/25, indicated Wanderguard to right wrist. Monitor for proper placement every shift and functioning daily. During an interview on 3/5/26 at 1:44 p.m., the MDS Coordinator indicated she thought the Wanderguard was discontinued. When asked for policy regarding MDS, she…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-06 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 observation, record review and interview, the facility failed to update care plans to reflect the resident's transfer status for 1 of 19 resident care plans reviewed. (Resident 16)Finding includes:On 3/2/26 at 3:18 p.m., Resident 16 was observed lying in bed. The resident indicated she required a Hoyer lift (mechanical device to transfer an individual) for staff to transfer her out of bed. Sometimes the facility was short staffed and they would not always have 2 staff members to transfer her out of bed.Record review for Resident 16 was completed on 3/3/26 at 2:14 p.m. Diagnoses included, but were not limited to stroke and anxiety.The Annual Minimum Data Set (MDS) assessment, dated 12/2/25, indicated the resident was cognitively intact. The resident was dependent on staff for transfers.A Care Plan, dated 12/5/24 and revised 3/2/26, indicated the resident had a self care deficit related to impaired mobility. An intervention included for staff to assist with transfers.A Care Plan, dated 12/6/24 and revised 3/2/26, indicated the resident was at risk for falls due to 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-06 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to provide activities to support the psychosocial well-being of cognitively impaired, dependent residents for 1 of 1 resident reviewed for activities. (Resident H)Finding includes:On 3/2/26 at 10:18 a.m., Resident H was observed lying flat in bed with her eyes open staring at the ceiling. The bed had half side rails with padding on them and the curtain was pulled. The resident was unable to see out into the hall as her bed was furthest from the door. There was no television or music on at the time of observation. The resident was picking at her hair repeatedly. There was an activity occurring in the dining room at the time. On 3/2/26 at 2:59 p.m. and 3:10 p.m., Resident H was observed lying flat in bed with her eyes open staring at the ceiling. The bed had half side rails with padding on them and the curtain was pulled. The resident was unable to see out into the hall as her bed was furthest from the door. There was no television or music on at the time of observation. The resident was picking at her hair…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-06 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure residents received the necessary treatment and services related to not notifying the physician when a resident was having frequent diarrhea for 1 of 1 resident reviewed for constipation/diarrhea. (Resident 16) The facility also failed to ensure physician's orders were followed related to a resident's catheter securement device for 1 of 1 resident reviewed for catheters. (Resident 52) Findings include:1. On 3/2/26 at 3:18 p.m., Resident 16 was observed lying in bed. The resident indicated she had been having episodes of diarrhea for a while. Record review for Resident 16 was completed on 3/3/26 at 2:14 p.m. Diagnoses included, but were not limited to stroke and anxiety. The Annual Minimum Data Set (MDS) assessment, dated 12/2/25, indicated the resident was cognitively intact. The resident was dependent on staff for transfers and toileting hygiene. The resident was always incontinent of bowel and bladder. The March 2026 Physician's Order Summary (POS) indicated an order for loperamide (antidiarrheal…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-06 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide 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

    Based on observation, record review, and interview, the facility failed to provide treatment for limited range of motion related to splints not in place for 2 of 3 residents reviewed for range of motion (ROM). (Residents G and H)Findings include:1.On 3/2/26 at 11:10 a.m., Resident G was observed sitting in his wheelchair in his room. There was no splint in place to his left hand. The splint was observed on his bed. On 3/3/26 at 2:47 p.m., Resident G was observed lying in bed. There was no splint in place to his left hand. The splint was observed on the seat of his wheelchair. On 3/3/26 at 11:24 a.m., Resident G was observed lying in bed. There was no splint in place to his left hand. The splint was observed on the seat of his wheelchair. He indicated he had a splint that he would wear to on his left hand sometimes. He was unable to put it on himself and unsure when he was supposed to wear it. The resident's record was reviewed on 3/4/26 at 2:23 p.m. Diagnoses included, but were not limited to, hemiplegia left non dominant side. The Quarterly Minimum Data Set (MDS) assessment, dated…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 record review and interview, the facility failed to ensure residents were provided with adequate equipment to prevent falls for 1 of 5 residents reviewed for accidents. (Resident D)Finding includes:Resident D's record was reviewed on 3/3/26 at 3:10 p.m.The Quarterly Minimum Data Set (MDS) assessment, dated 12/16/25, indicated the resident was moderately cognitively impaired and was dependent on staff for showering/bathing.An Event: Safety Events - Fall, dated 3/3/26 at 10:27 a.m., indicated the resident had a fall in the shower room while receiving a shower. There were no injuries. A Progress Note, dated 3/3/26, indicated the shower chair tipped in the shower and the resident was lowered to the floor by the CNA. The resident did not hit her head. There were no injuries. The physician and Director of Nursing were notified.During an interview on 3/3/26 at 3:40 p.m., CNA 4 indicated she did not typically work on the unit that Resident D resides on, so for care questions she had to rely on the other aids that were there most often. She was told that the resident usually had a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-06 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure physician's orders were followed related to a fluid restriction for 1 of 1 resident reviewed for hydration. (Resident 52)Finding includes: Resident 52's record was reviewed on 3/4/26 at 11:31 a.m. Diagnoses included, but were not limited to, heart failure.The Quarterly Minimum Data Set (MDS) assessment, dated 12/2/25, indicated the resident was cognitively intact. A Care Plan, revised on 3/3/26, indicated the resident was on a fluid restriction. Interventions included, but were not limited to, fluid restrictions as ordered and monitor and record intake.A Physician's Order, dated 3/1/26, indicated document fluid intake with medication every shift. A Physician's Order, dated 3/2/26, indicated diet: regular and 1,200 milliliters (ml) per day fluid restriction. The Intake: Fluids documentation section indicated the resident had 1,030 ml on 3/1/26, 1,080 ml on 3/2/26, and 900 ml on 3/3/26. The March 2026 Medication Administration Record indicated the resident received 510 ml of fluid on 3/1/26, 540 ml of fluid on 3/2/26,…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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, record review, and interview, the facility failed to ensure residents received proper treatment and care related to oxygen administration, implementing physician's orders, and testing for a resident with respiratory symptoms for 2 of 3 residents reviewed for respiratory care. (Residents 32 and 12)Findings include:1.On 3/3/26 at 9:39 a.m. Resident 32 was observed seated at a table in the Main Dining Room. Oxygen was in place via nasal cannula and the portable tank was set at 2 liters. On 3/3/26 at 2:52 p.m. Resident 32 was observed in the Main Dining Room doing a coloring activity. Oxygen was in place via nasal cannula and the portable tank was set at 2 liters. On 3/4/26 at 11:29 a.m. Resident 32 was observed seated at a table in the Main Dining Room. Oxygen was in place via nasal cannula and the portable tank was set at 2 liters. Resident 32's record was reviewed on 3/4/26 at 11:58 a.m. Diagnoses included, but were not limited to, emphysema and asthma. A Physician's Order, dated 3/1/26, indicated oxygen 2-4 liters as needed (PRN) to keep sats above 90%. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-12 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 record review and interview, the facility failed to ensure a resident received care in accordance with professional standards of practice related to a lack of assessments with changes in condition after a fall including pain, weight bearing, and ambulation status which delayed treatment for a fractured right hip for 1 of 3 residents reviewed for quality of care. (Resident D)Finding includes:Resident D's record was reviewed on 11/12/25 at 1:18 p.m. The diagnoses included, but were not limited to, right hip fracture, Alzheimer's disease, dementia, and moderate intellectual disabilities.A Quarterly Minimum Data Set assessment, dated 10/21/25, indicated a severely impaired cognitive status, physical behaviors and rejection of care were present for one to three days and verbal behaviors were present for four to six days. There was no impairment of the upper and lower extremities. Supervision was required for dressing and hygiene. Bathing had been refused. He was independent for bed mobility, sitting 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · D2025-01-24 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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 a resident with a pressure ulcer received the necessary treatment and services to promote healing related to a treatment not implemented timely for 1 of 3 residents reviewed for pressure ulcers. (Resident 30) Finding includes: On 1/24/25 at 1:38 p.m., the resident's left foot DTI (deep tissue injury) was observed with LPN 1. There was a small circular dark purple area about 1 cm (centimeter) x 1 cm to the bottom lateral side of the foot. The resident's record was reviewed on 1/23/25 at 1:08 p.m. Diagnoses included, but were not limited to, hypertension, cerebral infarction, and Alzheimer's disease. The admission Minimum Data Set (MDS) assessment, dated 11/29/24, indicated the resident was cognitively impaired and had a current unhealed pressure ulcer/DTI. A Care Plan, updated 12/2/24, indicated the resident had a DTI to his left lateral foot. The interventions included to treat per Physician's order. A Progress Note, dated 11/22/24 at 1:42 p.m., indicated the resident was a new admission 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure fall precautions were in place for a resident with a history of falls for 1 of 3 residents reviewed for accidents. (Resident 52) Finding includes: On 1/21/25 at 11:23 a.m., Resident 52 was observed lying in bed. Her wheelchair was at her bedside. There were no anti-rollback bars noted to her wheelchair. On 1/22/25 at 2:53 p.m., Resident 52 was observed seated in her wheelchair in the hall near the Nurse's Station. There were no anti-rollback bars noted to her wheelchair. On 1/23/25 at 9:56 a.m., Resident 52 was observed seated in her wheelchair at the Nurse's Station. There were no anti-rollback bars noted to her wheelchair. The record for Resident 52 was reviewed on 1/22/25 at 1:14 p.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, anxiety disorder, and hypertension. The Significant Change Minimum Data Set (MDS) assessment, dated 12/26/24, indicated the resident was cognitively impaired. She had one fall with no injury since the prior assessment and required…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-24 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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, record review, and interview, the facility failed to ensure residents received proper treatment and care related to oxygen administration for 1 of 2 residents reviewed for respiratory care. (Resident 4) Finding includes: On 1/21/25 at 2:36 p.m., Resident 4 was observed seated in his wheelchair in the hallway outside his room. He had no oxygen in place. On 1/22/25 at 2:52 p.m., Resident 4 was observed seated in his wheelchair in the hallway outside his room. He had no oxygen in place. On 1/23/25 at 9:55 a.m., Resident 4 was observed seated in his wheelchair in the therapy room. He had no oxygen in place. Record review for Resident 4 was completed on 1/22/25 at 1:17 p.m. Diagnoses included, but were not limited to, congestive heart failure, chronic respiratory failure, and type 2 diabetes mellitus. The Annual Minimum Data Set (MDS) assessment, dated 1/7/25, indicated the resident was cognitively impaired and received oxygen therapy. A Care Plan, updated 1/7/25, indicated the resident had heart failure and chronic respiratory failure with a history of a pulmonary…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-24 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    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 attempt alternative measures and assess the necessity for bed rails for 1 of 1 resident reviewed for bed rails. (Resident 52) Finding includes: On 1/21/25 at 11:23 a.m., Resident 52 was observed lying in bed. There were half length side rails to the top of the bed on both sides. On 1/21/25 at 1:41 p.m., Resident 52 was observed lying in bed. There were half length side rails to the top of the bed on both sides. The record for Resident 52 was reviewed on 1/22/25 at 1:14 p.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, anxiety disorder, and hypertension. The Significant Change Minimum Data Set (MDS) assessment, dated 12/26/24, indicated the resident was cognitively impaired. She required partial to moderate staff assistance with bed mobility, was receiving hospice services, and bed rails were not used as a physical restraint. A Care Plan, updated 12/31/24, indicated the resident was at risk for falls due to weakness and impaired mobility. An intervention, dated 11/26/24,…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-18 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    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 residents were treated with dignity, related to urinary drainage bags not covered, for 2 or 4 residents reviewed for dignity. (Residents C and D) Findings include: 1. Resident C was observed on 10/18/24 at 4:19 a.m., 4:34 a.m., and 5:49 a.m. lying in bed. The urinary drainage bag was attached to the side of the bed closest to the door. The urinary drainage bag was uncovered with urine present and visible in the bag. Resident C's record was reviewed on 10/18/24 at 1:31 p.m. The diagnoses included, but were not limited to, cerebral palsy and moderate intellectual disabilities. A Quarterly Minimum Data Set (MDS) assessment, dated 9/29/24, indicated a moderately impaired cognitive status, was dependent for activities of daily living, and had an indwelling urinary catheter. 2. Resident D was observed asleep in bed at 4:30 a.m. The urinary catheter drainage bag was attached to the bed frame on the side of the bed and was uncovered with urine present and visible in the bag. During an observation on 10/18/24…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-18 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure residents who required assistance with activities of daily living (ADL's) received oral care and assistance with placement of eyeglasses for 2 of 3 residents reviewed for ADL's. (Residents B and D) Findings include: 1. During an observation on 10/18/24 at 6:30 a.m., CNA 3 and CNA 4 entered Resident B's room. CNA 3 washed the resident's face and checked to ensure she had not been incontinent of urine or bowel. A mechanical lift was used to transfer the resident from the bed to the Broda Chair (reclining chair). Her hair was brushed and the glasses were cleaned and applied. Oral care had not been completed. Resident B's record was reviewed on 10/18/24 at 9:07 a.m. The diagnoses included, but were not limited to, Alzheimer's disease. An Annual Minimum Data Set (MDS) assessment, dated 10/8/24, indicated long and short term memory problems and was dependent on staff for hygiene and oral hygiene. A Care Plan, dated 10/9/24, indicated a deficit in self care. The interventions indicated the staff were 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-18 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure a resident with a urinary catheter and history of urinary tract infections received proper care and services related to improper placement of the urinary catheter drainage bag and tubing, catheter care not completed, and the outlet tube was not disinfected after emptying the urinary drainage bag, for 1 of 2 residents reviewed for urinary catheters. (Resident D) Finding includes: During an observation on 10/18/24 at 4:52 a.m., Resident D was awake and sitting on the side of the bed. CNA 1 entered the room and asked the resident if he would like to get out of bed or lie back down. Resident D opted to get up for the day. The urinary drainage bag on the side of the bed contained a large amount of clear yellow urine. CNA 1 unattached the urinary drainage bag from the side of the bed and placed the bag on the floor. She changed the resident's pants and each time after threading the catheter through the leg of the pants, the drainage bag was placed on the floor. The urinary drainage bag laid on the floor…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-18 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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 correct Personal Protective Equipment (PPE) was used by a staff members (CNA 1 and CNA 6) when providing care to residents (Residents D and C) who were in Enhanced Barrier Precautions (EBP) for two random observations for infection control. Findings include: 1. During an observation on 10/18/24 at 4:52 a.m., CNA 1 entered Resident D's room and prepared to start the morning care without any PPE being worn. CNA 1 was stopped before care was started. CNA 1 indicated if the resident was on EBP, there was usually a cart outside of the room. She acknowledged a sign above the bed, which indicated the resident was on EBP. CNA 1 then donned the PPE and began the morning care. Resident D's record was reviewed on 10/18/24 at 2:10 p.m. The diagnoses included, but were not limited to, dementia, history of urinary tract infections, and urinary retention. An admission Minimum Data Set (MDS) assessment, dated 9/27/24, indicated a moderately impaired cognitive status, supervision was required for oral hygiene 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-12 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 observation, record review, and interview, the facility failed to ensure a care plan was reviewed and revised to include changes related to splint use for a resident with contractures for 1 of 16 resident care plans reviewed. (Resident 35) Finding includes: On 1/8/24 at 9:54 a.m., Resident 35 was observed in his bed. Both hands were contracted at the wrist (a fixed tightening of muscles that prevents normal movement of associated body part) and there were no splints in place. A sign above the bed indicated to place splints on both hands/arms in the morning and after dinner for 2-3 hours, unless he asked for them off. On 1/9/24 at 8:50 a.m. and 2:14 p.m., 1/10/24 at 8:32 a.m. and 9:58 a.m., the resident was observed without splints on his hands. The resident's record was reviewed on 1/10/24 at 8:40 a.m. Diagnoses included, but were not limited to, cerebral palsy, moderate intellectual disabilities and contracture of muscle multiple sites. The Quarterly Minimum Data Set assessment, dated 9/20/23, indicated the resident was cognitively intact, and was dependent on staff…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-12 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure residents received the necessary treatment and services related to the lack of monitoring and assessments of skin discolorations for 1 of 1 residents reviewed for non-pressure skin conditions. (Resident 43) Finding includes: On 1/9/24 at 8:52 a.m., Resident 43 was lying in bed. There were 2 dark red/purple discolorations observed to her left forearm and 1 dark red/purple discoloration observed to her left wrist. On 1/10/24 at 1:10 p.m., Resident 43 was observed lying in bed. The same discolorations were still observed. Record review for Resident 43 was completed on 1/10/24 at 1:14 p.m. Diagnoses included, but were not limited to, dementia. The Quarterly Minimum Data Set (MDS) assessment, dated 8/23/23, indicated the resident was cognitively impaired. The resident was an extensive 2+ assist for bed mobility, transfer and toilet use. She was an extensive 1 person assist for locomotion, dressing and personal hygiene. She was on hospice care. A Care Plan, dated 10/7/22 and revised 11/22/23, indicated 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-12 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide 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

    Based on observation, record review, and interview, the facility failed to ensure a resident received the necessary treatment to prevent a decrease in range of motion related to a hand splint not in place as recommended and no Physician's order for splints for 1 of 1 residents reviewed for positioning and mobility. (Resident 35) Finding includes: On 1/8/24 at 9:54 a.m., Resident 35 was observed in his bed. Both hands were contracted at the wrist (a fixed tightening of muscles that prevents normal movement of associated body part) and there were no splints in place. A sign above the bed indicated to place splints on both hands/arms in the morning and after dinner for 2-3 hours, unless he asked for them off. On 1/9/24 at 8:50 a.m. and 2:14 p.m., 1/10/24 at 8:32 a.m. and 9:58 a.m., the resident was observed without splints on his hands. The resident's record was reviewed on 1/10/24 at 8:40 a.m. Diagnoses included, but were not limited to, cerebral palsy, moderate intellectual disabilities and contracture of muscle multiple sites. The Quarterly Minimum Data Set assessment, dated…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-12 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    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 a resident's pain was managed and monitored for 1 of 1 residents reviewed for pain. (Resident 19) Finding includes: During an interview with a family member of the resident on 1/10/24 at 9:02 a.m., he indicated she would frequently complain of pain to her knees. On 1/10/24 at 1:20 p.m., Resident 19 was heard moaning in her room from the hall. The resident was observed lying in her bed, she was grimacing and indicated she was having pain. She was unable to state where the pain was but indicated she needed help. RN 1 indicated at that time, the resident would do that frequently and that was normal for her, she received scheduled pain medication. She indicated she would see if there was something else she could have. The resident's record was reviewed on 1/10/24 at 11:05 a.m. Diagnoses included, but were not limited to, dementia, osteoarthritis, cerebral vascular accident and depression. The resident also received hospice services. The Quarterly Minimum Data Set assessment, dated 8/30/23, indicated 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-12 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy to reduce antibiotic resistance related to hospice prescribing antibiotics for a urinary tract infection without a urinalysis and culture completed for 1 of 3 residents reviewed for antibiotic use. (Resident 43) Finding includes: Record review for Resident 43 was completed on 1/10/24 at 1:14 p.m. Diagnoses included, but were not limited to, dementia. The Quarterly Minimum Data Set (MDS) assessment, dated 8/23/23, indicated the resident was cognitively impaired. The resident was an extensive 2+ assist for toilet use. She was on hospice care and received an antibiotic. A Physician's Order, dated 8/22/23-9/1/23 and again on 9/13/23-9/22/13, was for Cipro (antibiotic) 500 mg (milligrams) twice a day. A Physician's Order, dated 10/14/23, was for ceftriaxone (antibiotic) 1 gram injection 1 time only. A Physician's Order, dated 10/14/23-10/20/23, was for Augmentin (antibiotic) 500-125 mg twice a day. Review of the August, September and October…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-12 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure resident equipment was safe and functional related to torn and ripped armrests on a resident's wheelchair for 1 of 1 random observations of resident equipment. (Resident 108) Finding includes: On 1/9/24 at 9:48 a.m., Resident 108 was observed seated in her wheelchair. The armrests on both sides were ripped and torn. On 1/10/24 at 8:32 a.m., the resident was seated in the dining room, the arm rests on her wheelchair were ripped and torn. The resident's record was reviewed on 1/10/24 at 11:05 a.m. Diagnoses included, but were not limited to, dementia, osteoarthritis, cerebral vascular accident and depression. The resident also received hospice services. The Quarterly Minimum Data Set assessment, dated 8/30/23, indicated the resident had severe cognitive impairment, and had frequent pain which she received scheduled medication for. During an interview with Occupational Therapy Assistant 1 on 1/11/24 at 9:05 a.m., she indicated she had not previously noticed the torn armrests, but had notified maintenance…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2024-01-12 · tag F0638 — pattern
    Assure that each resident’s assessment is updated at least once every 3 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to complete a Quarterly Minimum Data Set (MDS) assessment timely for 6 of 19 residents whose MDS assessments were reviewed. (Residents 8, 25, 29, 17, 19, and 42) Findings include: 1. The Resident Assessment Task MDS tracking data indicated Resident 8's last MDS assessment was over 120 days old. Record review for Resident 8 was completed on 1/10/24 at 9:12 a.m. An Annual Minimum Data Set (MDS) assessment was completed on 8/23/23. The Quarterly MDS assessment, dated 11/22/23, had multiple incomplete sections and indicated it was in process. 2. The Resident Assessment Task MDS tracking data indicated Resident 25's last MDS assessment was over 120 days old. Record review for Resident 25 was completed on 1/10/24 at 9:12 a.m. An Annual Minimum Data Set (MDS) assessment was completed on 8/24/23. The Quarterly MDS assessment, dated 11/22/23, had multiple incomplete sections and indicated it was in process. 3. The Resident Assessment Task MDS tracking data indicated Resident 29's last MDS assessment was over 120 days old. Record…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
JAMES, WALTERIndividualCONTRACTED MANAGING EMPLOYEEsince 01/01/2017
RICHARDS, JANETIndividualCONTRACTED MANAGING EMPLOYEEsince 01/01/2017
CONRAD, KYLEIndividualW-2 MANAGING EMPLOYEEsince 01/01/2017
DEWING, SHARONIndividualW-2 MANAGING EMPLOYEEsince 01/01/2017
VELD, DIANEIndividualW-2 MANAGING EMPLOYEEsince 01/01/2017
BOARD OF COMMISSIONERS OF NEWTON COUNTYOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2017
GEORGE ADE MEMORIAL HEALTH CARE CENTER INC.OrganizationOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2017

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

2 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.

$6.6M
Net patient revenuemost recent cost report
+7.6%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 0%Medicare 7%Other / private 93%

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

$331per resident / day
operating cost
$10,069per month
≈ monthly operating cost
$358per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Indiana
$8,943/mo
Nursing home (semi-private)
$10,326/mo
Nursing home (private)
$5,639/mo
Assisted living

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 155719. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-06, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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