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Brownsburg Meadows

2 E Tilden, Brownsburg, IN 46112 · Government - County · 147 certified beds · (317) 852-8585 Medicare & Medicaid certified

Call the home — (317) 852-8585 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0602) — cited Oct 20251 actual-harm citation
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited Oct 2025
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • about 27% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 3 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
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
21 W MAIN St · (317) 852-2763 · Call to confirm hours
Pharmacy
26 S Green St · (317) 286-3506 · Call to confirm hours
Grocery
High Wave0.7 mi
422 E Main St · (317) 946-6226 · Call to confirm hours
Park
605 S Stephen Dr · (317) 858-4172 · Typically dawn to dusk
Place of worship

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 5 of 5
Long-stay residentspeople who live here 5 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 held steady at 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 increased4.0%11.0%15.4%better
Long-stay residents who lose too much weight3.4%5.5%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.2%1.1%2.0%better
Long-stay residents with depressive symptoms49.2%25.2%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.2%0.0%0.1%worse than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.4%3.9%3.3%better
Long-stay residents whose ability to walk worsened5.1%11.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication17.6%23.5%18.9%typical
Long-stay residents given the seasonal flu vaccine96.7%95.4%95.3%typical
Long-stay residents with pressure ulcers1.6%3.6%4.7%better
Long-stay residents with worsening bladder/bowel control18.4%23.3%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table9.7%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 vaccine51.3%79.0%79.4%worse
Short-stay residents rehospitalized after admission19.1%22.2%22.6%better
Short-stay residents with an outpatient ER visit10.7%10.8%12.0%better
Long-stay hospitalizations per 1,000 resident days1.241.611.67better
Long-stay outpatient ER visits per 1,000 resident days0.411.441.80better

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.

61.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 211 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

61.6%U.S. median 51.5%
Got home and stayed home
9.9%U.S. median 10.7%
Went back to hospital
44.1%U.S. median 56.6%
Met the expected recovery
0.25U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 44.1% 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 102 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 0.25 therapist hours per resident per day in 2026Q1 — more than 34% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF61.6%CMS range 54.1–68.451.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.9%CMS range 7.1–13.110.7%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 discharge44.1%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 discharge46.1%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 discharge33.3%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 identified89.7%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 setting88.9%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge96.0%98.7%Oct 2024–Sep 2025CMS 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 stay1.6%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 worsened0.8%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 hospitalization5.3%CMS range 3.2–8.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.011.02Oct 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

0.60
RN hours/ resident / day
0.78
LPN hours/ resident / day
2.08
Aide hours/ resident / day
3.46
Total nurse hours/ resident / day
0.41
RN hoursweekends
38.7%
Total nursing turnover
42.9%
RN turnover

How full it usually is: this home is certified for 147 beds and averages 131.2 residents a day — about 89% occupied, or roughly 16 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 3.46 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.08 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 2.93 hrs/resident/day on weekends vs 3.67 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.68 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 39% 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

7
deficiencies at the latest standard inspection (2025-04-25)
6
at the previous standard inspection (2024-02-27)

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.

24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.

  • Actual harm · Gcited before2025-09-04 · 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, interview, and record review, the facility failed to ensure a resident was mechanically transferred using proper technique, resulting in harm when a resident had a fall resulting in an avulsion fracture at the tip of the distal fibula for 1 of 3 residents reviewed for falls with injury (Resident D). Findings include: A Facility Reported Incident (FRI), dated 8/30/25 at 4:39 p.m., indicated on 8/29/25 Resident D was being assisted with a transfer out of her wheelchair by Certified Nursing Assistant (CNA) 10 when the resident began to experience pain in her right foot. The resident was gently lowered to the floor. On 8/31/25 Resident D was diagnosed with a probable subacute nondisplaced demineralized medial cuneiform (bones between the toes and ankle) fracture. The resident's activity level was upgraded to include non-weight bearing on the right lower extremity (RLE), and total mechanical lift for all transfers. On 9/3/25 at 2:28 p.m., Resident D was observed in a wheelchair (WC) at bedside, wearing a controlled ankle motion boot (CAM boot - a specialized walking…

    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 · D2026-04-16 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to honor a resident's right to dignity when she was kissed by a facility bus driver for 1 of 3 residents reviewed for resident abuse (Resident B). Findings include:A facility reported incident (FRI), dated 2/24/26 at 4:01 p.m., indicated Resident B reported a bus driver placed an unwanted kiss her on the forehead during transport. Bus Driver 5 was suspended pending investigation then later brought back with education. The resident care plan and profile were reviewed and updated, and the resident would be transported by third-party vendor to future appointments. Resident B's clinical record was reviewed on 4/15/26 at 11:32 a.m. Resident B was admitted on [DATE] with diagnoses that included spinal stenosis with fusion of the lumbosacral spine and admission for orthopedic aftercare. An admission Minimum Data Set (MDS) assessment, completed on 2/3/26, assessed Resident B as being cognitively intact with no documentation of behaviors or rejection…

    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 · E2025-10-16 · tag F0602 — failed to protect residents from theft of their belongings — pattern
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and record review, the facility failed to ensure residents' narcotic medications were protected from diversion resulting in 21 missing Oxycodone (a Schedule II narcotic medication) tablets, for 1 of 3 residents reviewed for misappropriation (Resident B). This deficient practice was corrected by 9/29/25 prior to the start of the survey and was therefore Past Noncompliance.Findings include:A Facility Reported Incident (FRI), dated 9/19/25 at 3:59 p.m., indicated a medication discrepancy was found with Resident B's pain medication from the pharmacy. The Executive Director (ED), Director of Nursing Services (DNS), Physician (MD), Power of Attorney (POA), pharmacy, police department, and Adult Protective Services (APS) were notified, and a consumer complaint was filed. Registered Nurse (RN) 6 was suspended pending investigation and subsequently terminated. Resident B's clinical record was reviewed 10/16/25 at 10:45 a.m. Diagnoses on Resident B's profile included traumatic subdural hemorrhage with loss of consciousness (brain bleed), and chronic obstructive 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · E2025-10-16 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and record review, the facility failed to maintain a system for the reconciliation of controlled medications, resulting in diversion of at least 369 Oxycodone (a Schedule II narcotic medication) tablets from 4 of 4 hallways reviewed for diversion of narcotics (100, 200, 300, and 400 hallways). This deficient practice was corrected by 9/29/25 prior to the start of the survey and was therefore Past NoncomplianceFindings include:A Facility Reported Incident (FRI), dated 9/19/25 at 3:59 p.m., indicated a medication discrepancy was found with Resident B's pain medication from the pharmacy. The Executive Director (ED), Director of Nursing Services (DNS), Physician (MD), Power of Attorney (POA), pharmacy, police department, and Adult Protective Services (APS) were notified, and a consumer complaint was filed. Registered Nurse (RN) 6 was suspended pending investigation and subsequently terminated.A Controlled Medication Reconciliation pharmacy audit report dated 8/22/25 - 9/22/25, documented 14 residents having been audited for narcotic medications. The audit indicated…

    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.

    Pharmacy Service Deficiencies · Past Non-Compliance
  • Potential for harm · Ecited before2025-04-25 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    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 A. Based on record review and interview, the facility failed to obtain resident weights as ordered for 2 of 2 residents reviewed for weights (Resident 74 and 107). B. Based on observations, interview and record review, the facility failed to ensure a newly admitted resident, (Resident C) had physician's orders in place and treatments rendered for a new surgical wound upon his admission for 1 of 5 residents reviewed for quality of care. C. Based on record review and interview the facility failed to ensure a resident's (Resident B) physician's ordered were followed to apply and remove a transdermal medication patch for 1 of 5 residents reviewed for quality of care. Findings include: A1. On [DATE] at 11:04 a.m., a record review was completed for Resident 74. She had the following diagnoses which included but were not limited to dementia, hyperlipidemia (high cholesterol), depression, and insomnia. She had an order, dated [DATE], to obtain her weight weekly on Monday. Her weight was not obtained on [DATE], [DATE]…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-25 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure 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 observations and interviews, the facility failed to date insulin and eye drops when opened and failed to remove expired tuberculin serum and insulin from the refrigerator for 3 of 6 medication carts and 2 of 4 medication rooms. Findings include: On [DATE] at 1:03 p.m., 200 hall medication cart was observed. Resident 282 had an insulin pen dated [DATE]. Resident 281 had a vial of folic acid inside the refrigerator on 200-hall that was undated. The 300-hall medication cart was observed. Resident 25 had a NovoLog insulin pen undated, and glargine insulin pen undated. Resident 86 had an insulin pen Semglee with no date to indicate when it was opened. Resident 38 had a bottle of brimodine 0.2% with no date to indicate when it was opened. The 300-hall medication room was observed. Inside the refrigerator was a vial of tuberculin serum that had a date of [DATE] on it. The 400-hall back medication cart was observed. Resident 1 had a insulin pen glargine with no date to indicate when it was opened. On [DATE] at…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-25 · tag F0624 — isolated
    Prepare residents for a safe transfer or discharge from the nursing home.
    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 safe and orderly discharge from the facility for 1 of 1 residents (Resident 118) reviewed for transfers and discharges. Findings include: On 4/21/25 at 9:58 a.m. Resident 118 was observed as she lay in bed. There was a catheter drainage bag hanging on the side of the bed, with a small amount of dark yellow urine in the tubing. Resident 118 indicated that she was unhappy with her stay at the facility, and she wanted to leave. She did not know why she had a catheter, and she complained of being constipated for a week. On 4/24/25 11:04 a.m. Resident 118's medical record was reviewed. She was a rehabilitation resident whose diagnoses included but were not limited to malignant neoplasm of the larynx (throat cancer), constipation, and urinary tract infection (UTI). A progress note, dated 4/21/25 at 1:38 p.m., indicated an unidentified staff member was walking past the nurses' station when Resident 118 and her family member walked by with a couple of bags with them. They indicated Resident 118 was going…

    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 · D2025-04-25 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record reviews, the facility failed to ensure a newly admitted resident, (Resident C) had a baseline care plan in place to address his immediate medical needs for a new surgical wound upon his admission for 1 of 3 new admission records reviewed. Findings include: 1. On 4/21/25 at 9:50 a.m. Resident C's wife was observed as she left the hall and stopped a nurse to ask about her husband's leg. She indicated to the unidentified nurse that his leg was still bleeding and had gotten all over his sheets. On 4/21/25 at 10:32 a.m., Resident C was observed as he laid in bed. He had a left below the knee amputation (BKA) which was wrapped up however, he had bleed through the dressing and bandage. A folded sheet had been placed under his soiled dressing and there was a moderate amount of bright red stains on the white sheet as well. Resident C indicated, he admitted to the facility on Friday the 18th. Everything had been find at the hospital after his amputation, but shortly after he arrived to the facility, he noticed he started bleeding through 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-25 · 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, interview and record review, the facility failed to ensure a resident (Resident 87) received care plan revisions to implement new goals and/or approaches to address her diabetic management for 1 of 5 residents reviewed for unnecessary medications. Findings include: On 4/22/25 at 9:00 a.m., Resident 87 was observed in bed. A over-bed table with a breakfast tray was observed in front of her, but Resident 87 indicated she did not want to eat her breakfast. Resident 87 indicated she did not like the food and because of her diabetes, there were certain things she could or could not eat. On 4/23/25 at 10:16 a.m., Resident 87's medical record was reviewed. She was a long-term care resident with diagnoses which included, but were not limited to diabetes mellitus type II (a blood sugar disorder) and kidney failure. A nursing progress note, dated 2/21/25 at 10:14 p.m., indicated, Resident 87 had refused all evening medications and refused to have her blood glucose checked. She was asked three separate times but remained adamant about her refusal. An interdisciplinary…

    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 before2025-04-25 · 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 and interview, the facility failed to prevent the potential for accidents when medications were left bedside with residents without self-administration assessments for 2 of 2 random observations (Residents 78 and 118), and when a nurse was observed leaving medications unattended on top of the medication cart during a medication pass observation which had the potential to affect 2 of 2 residents in the hallway when the medication was unattended. Findings include: 1. On 4/20/25 at 9:46 a.m. Resident 78 was observed sitting up in his wheelchair. On his bedside table was a clear cup and inside there were 7 pills ranging in color and size. Resident 78 indicated he had not taken them yet because he had an upset stomach. He indicated the nurse left them there for him to take. A record review was completed. Resident 78 had the following diagnoses which included but were not limited to cerebral infarction (stroke), type 2 diabetes, difficulty swallowing, hyperlipidemia, and hypertension. On 4/23/25 at 1:30 p.m., the Director of Nursing (DON) indicated Resident 78 lacked…

    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 · D2025-04-25 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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

    Based on observations, interviews and record review the facility failed to ensure the medical record reflected accurate documentation of a pressure injury for a resident for 1 of 25 residents reviewed for accurate documentation (Resident 16). Findings include: On 4/22/25 at 10:15 a.m., Resident 16 was observed as he lay in bed. He was pleasantly confused at times, but he could answer most questions appropriately. He had a pressure-relieving boot on his right heel and another pressure-relieving boot was on the floor at the foot of the bed. On 4/24/25 at 1:35 p.m., Resident 16's medical record was reviewed. He was a long-term care resident whose diagnoses included but were not limited to Type 2 Diabetes and Urinary Tract Infections (UTI). A progress note, dated 11/15/24 at 10:35 p.m., indicated Resident 16 arrived at the facility in a wheelchair with bilateral edema in his lower extremities and a pressure ulcer on his right heel. A progress note, dated 3/16/25 9:59 p.m., indicated Resident 16 had a dressing changed to his right heel ulcer. An admission assessment, dated 11/15/24,…

    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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · D2025-01-24 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to manage Peripherally Inserted Central Catheter (PICC) line dressing changes for a resident receiving intravenous (IV) antibiotics to treat extradural and subdural abscesses for 1 of 2 residents reviewed for PICC line dressing changes (Resident C). Findings include: During an interview on 1/22/25 at 10:41 a.m., a resident representative indicated Resident C had been admitted to the facility from a local hospital on [DATE] with orders to change his PICC line dressing weekly, but the facility did not have his PICC line dressing changed until close to discharge over 3 weeks later. The resident representative indicated they had repeatedly taken their concerns to the Infection Preventionist nurse and floor nurses. They had even brought up their concerns during a care plan meeting on 11/19/24 with a picture of his dressing dated 10/28/24 from the hospital and the PICC dressing coming loose around the edges as proof, but the facility did not…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-10 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, observation, and record review, the facility failed to ensure residents' rooms and bathrooms were cleaned daily and the residents' shower rooms were kept clean and uncluttered for 3 of 4 shower rooms observed. This had the potential to affect 136 of 136 residents who resided in the facility. Findings include: During an interview Resident B's family member, on 7/9/24 at 10:36 a.m., indicated housekeeping services were not provided on a regular basis. On 7/10/24 at 10:17 a.m., Resident F's family member indicated she visited her husband daily. The resident's room and bathroom were not cleaned routinely. She had complained about the uncleaned room and bathroom previously, in March 2024, during a care plan meeting and had filed a grievance, on 6/3/2024, about the cleanliness of the resident's room. The next day, on 6/4/24, the room and bathroom were cleaned. Now, on the floor, there was dirt, dust, debris and the toilet in the bathroom was also dirty. Resident F and his roommate, Resident H, were bedridden and did not use the toilet, but occasionally the residents'…

    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 · Ecited before2024-02-27 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure 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 and interview, the facility failed to properly label medications with dates when they were opened and failed to dispose of expired insulin for 3 of 5 medication room observed and 3 of 6 medication carts observed. Findings include: 1. On [DATE] 10:01 a.m., RN 27 provided an escort to check medication rooms and medication carts for labeling and dating of medications. Upon observation of the 200 Front medication room, a bottle of tuberculin serum was found rolling around in the door of the refrigerator. The multi-dose vial lacked a date to indicate when it was opened. 2. On [DATE] at 10:12 a.m., the 300-medication cart was observed. a. Resident 17 had a bottle of refresh eye drops (a lubricant for the eyes). The bottle was not opened and a label on the bottle indicated to refrigerate. b. Resident 96 had a bottle of ipratropium 0.3% spray for the nose (used for runny and nasal stuffiness) lacked a date when opened. c. Resident 72 had a bottle of fluticasone prop 50 mcg spray (used for…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-27 · 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 observation, interview, and record review, the facility failed to identify bruising timely and failed to accurately document a new skin area on her chest for 1 of 1 residents reviewed for hospice and end of life services (Resident 4). Findings include: On 2/19/24 at 11:50 a.m., Resident 4 was initially observed. There was a large irregularly shaped bruise on the middle of her left upper arm. It was dark purple and green, with a raised bump in the middle of the bruise. A second more faded bruise was observed on her upper left shoulder as well. Resident 4 indicated she did not know what happened, and it was a little tender as she touched the area. During an interview on 2/21/24 at 1:26 p.m., Unit Manager (UM) 28 indicated, any new skin issues, open areas or bruises should be documented in the Resident's record as a new skin event, and followed up with a progress note and wound referral. At that time, UM 28 reviewed Resident 4's record skin events and progress notes but indicated there was no documentation…

    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 before2024-02-27 · 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 observation, interview, and record review, the facility failed to ensure medications and wound cleanser were secure and not found in an unlocked memory care (MC) linen closet for 18 of 28 residents who resided in the MC unit. The facility failed to ensure medications were not found in resident's rooms without self-administration assessments for 4 of 4 residents reviewed for self-administration assessments (Resident 27, 68, 190, and 88). Findings include: 1 On 2/19/24 at 10:34 a.m., the MC linen closet was observed to be unlocked. Unlabeled and opened containers of nystatin topical powder (treats fungal skin infections), Calmoseptine (barrier skin cream), and an almost full 8 ounce bottle of wound cleanser were found in the room. On 2/19/24 at 11:00 a.m., Licensed Practical Nurse (LPN) 9 indicated the MC linen closet should have been locked. She indicated the nystatin powder, Calmoseptine, and wound cleanser should have been locked up because a memory care resident could have come in the linen closet 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-27 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a resident, (Resident 70) who had recent medication adjustments and fluctuating blood pressures, received timely documentation from his Dialysis center after treatment sessions to ensure continuity of and to prevent the potential for complications related to post-Dialysis change of condition for 1 of 1 resident reviewed for Dialysis. Findings include: On 2/22/24 at 10:12 a.m., Resident 70's medical record was reviewed. He was a long-term care resident who had diagnoses which included, but were not limited to, end-stage renal disease and was dependent on renal dialysis and hypertensive heart disease. Resident 70's nursing progress notes were reviewed and revealed recurrent fluctuating blood pressures and the need for administration of as needed medications (PRN), which included, but were not limited to: a. 1/10/24 at 3:25 a.m., Resident BP checked and was at 179/106. PRN clonidine administered. Writer re-checked BP later and was 154/96. Resident stable and resting at this time. Will continue to monitor progress b.…

    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 before2024-02-27 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure 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 provide appropriate hand hygiene while assisting residents with eating for 2 of 2 days of dining observations. (Resident 44, 89, 42, 76, 110, 84, 42, and 56). Findings include: On 2/19/24 at 12:33 p.m., Qualified Medication Aide (QMA) 14 was observed to cut up Resident 95's food, did not wash or gel her hands and provided food for Resident 44. On 2/19/24 at 12:35 p.m., the Memory Care Support Specialist (MCSS) was observed to move a dining room chair with his bare hands, did not wash or gel his hands, and provided food and cut-up food for Resident 89. On 2/19/24 at 12:36 p.m., QMA 14 provided Resident 42's food, she did not wash or gel her hands, and provided food for Resident 76, and without washing or gelling her hands, provided food for Resident 110. On 2/19/24 at 12:46 p.m., Licensed Practical Nursing (LPN) 16 pulled up a dining room chair with her bare hands, did not wash or gel her hands, then assisted Resident 84 with eating. On 2/19/24 at 12:51 p.m., QMA 14 left the dining room table while assisting…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-27 · tag F0908 — failed to keep essential equipment working — isolated
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure all mechanical equipment was kept in safe operating condition for 1 of 1 observation of the laundry service area. Findings include: On 2/23/24 at 11:00 a.m., during a routine observation of the laundry service area, soiled linen was in an uncovered barrel. Housekeeping Supervisor acknowledged all soiled linen was to be covered. Clean clothes were bagged and lying on the floor in the soiled linen area. The Housekeeping Supervisor indicated the items were clothes which had been placed there by the nurse aides and the clothing needed to be labeled. She indicated it was ok for the linen to be on the floor because it was in bags. A laundry rack containing clean unbagged linens was uncovered. Observation of the dryer lint traps indicated dryer number 3 had a minimal amount of lint. Dryers number 1 and 2 contained a large amount of lint in the lint traps. Review of the lint trap cleaning log dated, February 2024, lacked documentation of cleaning from 1am to time of observation. The housekeeping Supervisor acknowledged 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-04-04 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    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 observations, interviews, and record review, the facility failed to ensure respiratory equipment was stored properly to prevent the potential for cross contamination and infection for 3 of 11 residents reviewed for respiratory equipment/services and supplies (Residents 108, 334, and 184). Findings include: 1. During an observation on 3/29/23 at 9:57 a.m., Resident 108 was lying in his bed. He was alert. He had a Bi-pap machine sitting on his nightstand. The mask was not inside a protective bag. Resident 108 indicated he wore the mask 50% of the time and not all the time because the mask did not fit properly. He indicated he was not assessed for the fitting of his mask, now he was stuck with two masks that did not fit. He indicated his orders were for generic settings and not specific for him. A comprehensive record review was completed for Resident 108. He had the following diagnoses, but no limited to obstructive sleep apnea, neuromyelitis, type 2 diabetes, acute transverse myelitis in demyelinating disease of the central nervous system, pressure ulcer of sacrum, essential…

    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 · E2023-04-04 · tag F0757 — failed to avoid unnecessary drugs — pattern
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to include an indication for use of medications for 3 of 5 residents reviewed for unnecessary medications (Resident 108, 90, and 127). Findings include: 1. A comprehensive record review was completed for Resident 108. He had the following diagnoses, but no limited to neuromyelitis, type 2 diabetes, acute transverse myelitis in demyelinating disease of the central nervous system, pressure ulcer of sacrum, essential hypertension, atrial fibrillation, chronic embolism, gastro-esophageal reflux disease (GERD) and hyperlipidemia. Resident 108 had orders for the following medications. The medications did not include an appropriate indication for usage. a.) Benadryl (diphenhydramine hcl) 25mg capsule every 6 hours/PRN (as needed) for encounter for other specified aftercare. b.) Cholecalciferol (vitamin D3) 1,250 mcg (50,000 unit) capsule, once a day on the fourth Friday of the month for encounter for other specified aftercare. c.) Clorpactin WCS-90 (oxycholorosene sodium) reconstituted solution at bedtime Monday and Thursday,…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-04-04 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure 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 used appropriate hand hygiene while assisting residents with eating for 4 of 5 residents requiring assistance with eating in the memory care area (Resident 20, 34, 47, and 65) Findings include: On 3/29/23 at 12:57 p.m., Certified Nursing Aide (CNA) 7 was observed standing while assisting Resident 20 with her lunch. On 3/29/23 at 1:07 p.m., CNA 7 was assisting two residents with eating, Resident 20 and 65. She was observed touching Resident 20's clothing by rubbing her arm, then without hand washing, she used the same hand to provide several bites of food for Resident 65. On 3/29/23 at 1:09 p.m., CNA 7 was again observed to rub Resident 20's arm, then provided bites to Resident 65. She was observed using the same hand as she went back to forth while assisting Resident 20 and 65 with eating. On 3/29/23 at 1:11 p.m., CNA 6 was observed assisting two resident with eating, Resident 34 and 47. She was observed to provide several bites of food to Resident 47, then without hand washing and using the same…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-04 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure care plans were in place for 2 of 22 residents reviewed for care plans (Resident 119 and 184). Findings include: On 3/31/23 at 2:20 p.m., Resident 119's medical chart was reviewed. A new facility diagnosis, dated 2/3/23, indicated, other seizures. Further diagnoses were dementia progress degeneration of the brain), chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), history of multiple falls with fractures: sacrum, rubs, proximal right femur, weakness, history of falling, abnormalities of gait and mobility, unsteadiness on feet, and reduced mobility. A nursing progress note, dated 1/31/23 at 10:23 p.m., Licensed Practical Nurse (LPN) 15 indicated Resident 119 was sitting at a table at 6:48 p.m., when she observed the resident begin to actively seizure, noting her arms and legs stiffen and her body convulse (involuntary contraction of the muscles). Her head tilted back, her face flushed, and her eyes rolled…

    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 before2023-04-04 · 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 observations, interview and record review, the facility failed to ensure a resident who had a history of chronic venous ulcers and wound infections received interventions to prevent new areas from re-opening and becoming infected for 1 of 5 residents reviewed for nursing services (Resident C), and the facility failed to ensure a resident received a routine lab and complaints of acute pain noted on her Dialysis communication log were addressed for 1 of 5 residents reviewed for nursing services (Resident E). Findings include: 1. During a confidential interview, it was indicated, Resident C had been in a car accident in which her legs had been run over. She had broken her left ankle in three places and had bad road rash on her right leg. Before the accident she had struggled with poor circulation and sores, but the accident made it worse. She came for rehabilitation and had been going out-patient to a wound clinic for her legs. At the end of January, her leg wounds had healed, and she no longer 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

“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.

Part of a chain

This home belongs to AMERICAN SENIOR COMMUNITIES — 90 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 53.9-0.9 vs chain
Health inspection 2 of 53.4-1.4 vs chain
Staffing 2 of 52.3-0.3 vs chain
Quality measures 5 of 54.7+0.3 vs chain
The other 89 homes this chain runs (chain average 3.9★, per CMS)
1 of 5Valparaiso Care & RehabilitationValparaiso, IN 2 of 5Arbor Grove VillageGreensburg, IN 2 of 5Bethany VillageIndianapolis, IN 2 of 5Columbia Healthcare CenterEvansville, IN 2 of 5Community Nursing And Rehabilitation CenterIndianapolis, IN 2 of 5Eagle Valley MeadowsIndianapolis, IN 2 of 5Harcourt Terrace Nursing And RehabilitationIndianapolis, IN 2 of 5Harrison TerraceIndianapolis, IN 2 of 5Hickory Creek At New CastleNew Castle, IN 2 of 5Maple Park VillageWestfield, IN 2 of 5Park Terrace VillageEvansville, IN 2 of 5Riverside VillageElkhart, IN 2 of 5Trailpoint VillageSouth Bend, IN 2 of 5University Nursing CenterUpland, IN 2 of 5Williamsport Nursing And RehabilitationWilliamsport, IN 3 of 5Allisonville MeadowsFishers, IN 3 of 5American VillageIndianapolis, IN 3 of 5Countryside MeadowsAvon, IN 3 of 5East Lake Nursing & Rehabilitation CenterElkhart, IN 3 of 5Hickory Creek At CrawfordsvilleCrawfordsville, IN 3 of 5Hillcrest VillageJeffersonville, IN 3 of 5North Capitol Nursing & Rehabilitation CenterIndianapolis, IN 3 of 5Rosebud VillageRichmond, IN 3 of 5Rosewalk VillageIndianapolis, IN 3 of 5Rosewalk Village At LafayetteLafayette, IN 3 of 5Spring Mill MeadowsIndianapolis, IN 3 of 5Stonebrooke Rehabilitation CenterNew Castle, IN 4 of 5Autumn Ridge Rehabilitation CentreWabash, IN 4 of 5Beech Grove MeadowsBeech Grove, IN 4 of 5Clark Rehabilitation And Skilled Nursing CenterClarksville, IN 4 of 5Clinton GardensClinton, IN 4 of 5Creekside VillageMishawaka, IN 4 of 5Edgewater WoodsAnderson, IN 4 of 5Forest Creek VillageIndianapolis, IN 4 of 5Franklin MeadowsFranklin, IN 4 of 5Heritage House Rehabilitation & Health Care CenterConnersville, IN 4 of 5Hickory Creek At ColumbusColumbus, IN 4 of 5Hickory Creek At MadisonMadison, IN 4 of 5Hickory Creek At PeruPeru, IN 4 of 5Hickory Creek At RochesterRochester, IN

Showing 40 of 89; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
DRUMMER, CARLIndividualCORPORATE DIRECTORsince 01/01/2017
FEHRIBACH, GREGORYIndividualCORPORATE DIRECTORsince 12/14/2004
HANIFY, THOMASIndividualCORPORATE DIRECTORsince 01/01/2022
HARRIS, LISAIndividualCORPORATE DIRECTORsince 12/22/2003
LAZARD, ROBERTIndividualCORPORATE DIRECTORsince 01/29/2021
MANTRAVADI, GEETAIndividualCORPORATE DIRECTORsince 07/21/2021
MUKES-GAITHER, BEVERLYIndividualCORPORATE DIRECTORsince 01/01/2022
PAYNE, MONICAIndividualCORPORATE DIRECTORsince 08/09/2021
BABCOCK, PAULIndividualCORPORATE OFFICERsince 09/30/2020
CAINE, VIRGINIAIndividualCORPORATE OFFICERsince 01/10/1994
AMERICAN SENIOR COMMUNITIES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2009
BROOKS, JOCELYNIndividualOPERATIONAL/MANAGERIAL CONTROLsince 07/25/2019
CLINE, JONATHONIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/23/2026
DICE, MARKIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2023
DURHAM, ROBERTIndividualOPERATIONAL/MANAGERIAL CONTROLsince 08/19/2019
METZLER, PAIGEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/31/2026
VAN CAMP, STEVENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2023

CMS files one row per role, so the 22 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner 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.

$16.9M
Net patient revenuemost recent cost report
-1.2%
Operating marginrevenue minus expenses
$4.7M
Related-party expense27% of expenses
Who pays — share of resident-days
Medicaid 57%Medicare 11%Other / private 31%

This home reported $4.7M paid to related parties — landlords or management companies under common ownership — equal to about 27% 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

$372per resident / day
operating cost
$11,315per month
≈ monthly operating cost
$368per 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 155761. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-25, 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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