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Restoracy Of Carmel

616 Green House Way, Carmel, IN 46032 · For profit - Limited Liability company · 72 certified beds · (317) 401-8888 Medicare & Medicaid certified

Call the home — (317) 401-8888 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0602) — cited Aug 2024
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited Aug 2024
  • a high number of inspection citations overall (23) — 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
  • nursing-staff turnover (66%) runs well above the national median (45%)

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 5 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
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1217 S Rangeline Rd · (317) 574-4680 · Call to confirm hours
Pharmacy
1421 S Rangeline Rd · (317) 844-2775 · Call to confirm hours
Grocery
622 S Rangeline Rd · (317) 654-8243 · Call to confirm hours
Park
365 Monon Blvd · (317) 571-2400 · 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 improved from 2 to 4 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 rating4★
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 increased6.7%11.0%15.4%better
Long-stay residents who lose too much weight8.5%5.5%5.4%worse
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 infection0.4%1.1%2.0%better
Long-stay residents with depressive symptoms67.4%25.2%6.5%worse 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 injury3.8%3.9%3.3%worse
Long-stay residents whose ability to walk worsened7.1%11.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication22.2%23.5%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.4%95.3%typical
Long-stay residents with pressure ulcers5.6%3.6%4.7%worse
Long-stay residents with worsening bladder/bowel control27.7%23.3%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table11.8%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 vaccine98.3%79.0%79.4%better
Short-stay residents rehospitalized after admission15.2%22.2%22.6%better
Short-stay residents with an outpatient ER visit7.4%10.8%12.0%better
Long-stay hospitalizations per 1,000 resident days1.091.611.67better
Long-stay outpatient ER visits per 1,000 resident days1.381.441.80better

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.

57.7% 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 84 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

57.7%U.S. median 51.5%
Got home and stayed home
10.6%U.S. median 10.7%
Went back to hospital
66.7%U.S. median 56.6%
Met the expected recovery
0.52U.S. median 0.31
Therapy hours / resident / day
0.21hours / resident / day
Physical therapy
0.25hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 66.7% 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 69 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 0.52 therapist hours per resident per day in 2026Q1 — more than 83% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF57.7%CMS range 45.7–66.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.6%CMS range 6.9–15.010.7%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 discharge66.7%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 discharge59.4%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 discharge63.8%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 identified98.7%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 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 discharge97.4%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 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 worsened0.0%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 hospitalization6.4%CMS range 3.7–10.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.841.02Oct 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

0.46
RN hours/ resident / day
0.98
LPN hours/ resident / day
4.14
Aide hours/ resident / day
5.57
Total nurse hours/ resident / day
0.28
RN hoursweekends
65.6%
Total nursing turnover
66.7%
RN turnover

How full it usually is: this home is certified for 72 beds and averages 68.7 residents a day — about 95% occupied, or roughly 3 beds typically open. It runs essentially full — expect a waiting list. 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 5.57 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 4.14 is at or above 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 5.40 hrs/resident/day on weekends vs 5.64 on weekdays — 4% thinner on weekends. RN hours go from 0.53 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 66% is well above the national median of 45%. 1 administrator has left in the past year.

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

6
deficiencies at the latest standard inspection (2026-02-20)
3
at the previous standard inspection (2025-02-26)

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.

23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.

  • Potential for harm · Ecited before2026-02-20 · tag F0880 — failed to prevent and control infections — pattern
    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 new residents were correctly screened for tuberculosis and staff wore protective gowns for enhanced barrier precautions for 5 of 7 residents reviewed for infection control. (Resident 18, 40, 43, 66 and 54)Findings include:1. The clinical record for Resident 18 was reviewed on 2/19/26 at 2:35 p.m. The diagnoses included, but were not limited to, hypertensive encephalopathy, hypertensive heart disease with heart failure, and hemiplegia and hemiparesis following a cerebral infarction affecting left non-dominant side. a. The Medication Administration Record (MAR), dated January 2026, indicated Resident 18 was given a tuberculin test on 1/6/26 at 11:27 p.m. The test was not read on 1/8/26 or 1/9/26 (48 to 72 hours after administration) due to the resident being out of the facility on leave of absence with his son. A nursing progress note, dated 1/9/26 at 5:29 p.m., indicated the tuberculin test was not read due to the resident being out of the facility. b. The MAR, dated January 2026, indicated the 2nd step…

    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 · D2026-02-20 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the physician was notified of a three (3) pound weight gain according to the physician's order for 1 of 3 residents reviewed for notification of change. (Resident 4)Findings include:The clinical record for Resident 4 was reviewed on 2/17/26 at 3:10 p.m. The diagnoses included, but were not limited to, heart failure, stage 3 chronic kidney disease, and type 2 diabetes.A care plan indicated Resident 4 was at risk for potential alteration of nutrition and weight status. Interventions included, but were not limited to, obtain and evaluate weights as ordered and notify the physician and family of any significant changes.A physician's order, with a start date of 10/3/24 and an end date of 1/7/26, indicated to weigh Resident 4 every Monday and Thursday and to notify the Nurse Practitioner (NP) for a weight increase of three (3) pounds.The following weights were documented in the clinical record:a. On 9/22/25, the weight was 239 pounds. On 9/25/25, the weight was 242.2 pounds. This was a gain of three (3) pounds or more.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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-20 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure proper discharge information was documented in the electronic health record for 3 of 6 residents reviewed for discharge. (Resident 5, 6 and 77)Findings include:1. The clinical record for Resident 5 was reviewed on 2/18/26 at 2:28 p.m. The diagnoses included, but were not limited to, repeated falls, traumatic subdural hemorrhage without loss of consciousness, and dementia.A nursing progress note, dated 1/6/26 at 8:00 p.m., indicated an order was received to send Resident 5 to the emergency room for an evaluation and treatment.A nursing progress note, dated 1/6/26 at 8:10 p.m., indicated an EMT (emergency medical technician) arrived at the facility to transport Resident 5 to the hospital.Resident 5 was discharged from the facility and admitted to the hospital from [DATE] to 1/9/26.The electronic health record did not contain documentation a report was called to the receiving facility, special instructions or precautions for ongoing care were…

    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 · Dcited before2026-02-20 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    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 Preadmission Screening and Resident Review (PASSAR) level I screen contained current mental health diagnoses and mental health medications for 1 of 2 residents reviewed for PASSAR. (Resident 75) The deficient practice was corrected on 2/12/26, prior to the start of the survey, and was therefore past noncompliance.Findings include:The clinical record for Resident 75 was reviewed on 2/19/26 at 8:48 a.m. The diagnoses included, but were not limited to, depression, anxiety, insomnia, and dementia.A PASSAR level I screen, dated 7/9/25, indicated no current or past mental health diagnoses were known or suspected. The current or past mental health medications were buspirone (an anxiety medication) and trazodone (used to treat insomnia and sometimes used to treat depression). The diagnosis for both medications was listed as unknown. The level I screen indicated there was no evidence of an intellectual/developmental disability or a serious behavioral health condition and if changes occurred or new information refutes 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 · Past Non-Compliance
  • Potential for harm · D2026-02-20 · tag F0755 — failed to provide safe pharmacy services — isolated
    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 observation, interview and record review, the facility failed to ensure a medication cart was free of expired medications for 1 of 3 medication carts reviewed for medication storage and labeling. (Cottage 3)Findings include:The Cottage 3 medication cart was reviewed on 2/19/26 at 11:33 a.m. The following was observed:a. In the narcotic lock box, lorazepam (an antianxiety medication) with an unknown prescription filled date and a quantity of 30 out of 30 was past the expiration date of 1/15/26.b. In the narcotic lock box, lorazepam with an unknown prescription filled date and a quantity of 4 out of 30 was past the expiration date of 12/18/25.During an interview, on 2/19/26 at 11:33 a.m., QMA (Qualified Medication Aide) 7 indicated pharmacy audited the medication carts monthly and the nurses would also monitor for expired medications.During an interview, on 2/19/26 at 2:05 p.m., the Executive Director (ED) indicated the facility did not have a policy regarding medication cart audits.A current facility policy, titled Storage of Medications, dated 5/20/20 and received from 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-20 · 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 ensure refrigerated food was not expired and refrigerators were maintained at proper temperatures for food safety for 2 of 6 refrigerators reviewed (Cottage 6) which supplied food to 2 of 6 cottages. (Cottage 1 and Cottage 6)Findings include:The kitchen in Cottage 6 was reviewed on 2/16/26 at 10:05 a.m. The following was observed:1. Refrigerator 2 which contained, but were not limited to, dairy products and mayonnaise.a. A tub of ricotta cheese with an expiration date of 2/13/26 was opened and less than half of the ricotta cheese remained in the container. Next to the opened and expired container was an unopened tub of Ricotta cheese with an expiration date not yet surpassed.b. An internal thermometer sat on the back of the top shelf and read fifty (50) degrees Fahrenheit.2. Refrigerator 3 which contained, but were not limited to, milk and condiments.a. An internal thermometer sat on the back of the top shelf and read forty-eight (48) degrees Fahrenheit.During an interview, on 2/16/26 at 10:09 a.m., the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-26 · 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, interview and record review, the facility failed to ensure urinary catheter bags had dignity covers in place for 2 of 3 residents reviewed for dignity. (Resident 40 and 52) Findings include: 1. During an observation, on 2/24/25 at 10:28 a.m., Resident 40 was in the TV area and his catheter bag did not have a dignity cover (a cover which blocked the appearance of urine in the catheter bag). The clinical record for Resident 40 was reviewed on 2/21/25 at 11:06 a.m. The diagnoses included, but were not limited to, benign prostatic hyperplasia, other obstructive and reflux uropathy, and hypertension. A physician's order, with a start date of 1/22/23, indicated the resident had a urinary catheter. A current urinary catheter care plan indicated to encourage/assist the resident to obscure visibility of the drainage bag with a dignity cover as appropriate. During an interview, on 2/24/25 at 10:57 a.m., Licensed Practical Nurse (LPN) 4 indicated the catheter bag did not have a dignity cover. 2. During an observation, on 2/20/25 at 10:23 a.m., Resident 52 was out in 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-26 · 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 interview and record review, the facility failed to ensure staff followed the physician's orders regarding medication administration for 2 of 2 residents reviewed for quality of care. (Resident 19 and 7) Findings include: 1. The clinical record for Resident 19 was reviewed on 2/21/25 at 11:42 a.m. The diagnoses included, but were not limited to, type 2 diabetes, heart failure, and hypertension. A physician's order, with a start date of 5/14/24, indicated to give hydralazine (a medication to lower blood pressure) 10 milligrams (mg) every 4 hours as needed for a systolic blood pressure (SBP) above 170. The medication administration record (MAR) indicated the following: On 9/28/24, the systolic blood pressure was 195. hydralazine was not given. On 10/4/24, the systolic blood pressure was 175. hydralazine was not given. On 10/25/24, the systolic blood pressure was 171. hydralazine was not given. On 11/25/24, the systolic blood pressure was 179. hydralazine was not given. During an interview, on 2/24/25 at 11:41 a.m., the Director of Nursing (DON) indicated the medication should…

    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 before2025-02-26 · 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 catheter bags were not touching a dirty surface and catheters were disposed of properly for 3 of 5 residents reviewed for infection control. (Resident 52, 7 and 44) Findings include: 1. During an observation, on 2/19/25 at 10:10 a.m., Resident 52's catheter bag was resting on his Broda chair's footrest (a specialty wheelchair). The residents' feet were resting on top of the catheter bag. During an observation, on 2/19/25 at 10:12 a.m., a staff member transported the resident to the TV area from the dining table. During an observation, on 2/19/25 at 12:30 p.m., Resident 52's feet were still resting on his catheter in the same position. No staff had noticed the placement of the catheter bag. The clinical record for Resident 52 was reviewed on 2/21/25 at 10:55 a.m. The diagnoses included, but were not limited to, chronic kidney disease, neuromuscular dysfunction of the bladder, and muscle weakness. A physician's order, with a start date of 1/21/25, indicated the resident had a Foley catheter for urinary…

    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 · D2024-08-07 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    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' credit cards were kept safe and secure during their admission for 2 of 3 residents being reviewed for misappropriation of property. (Residents B and C) The deficient practice was corrected on 8/5/24, prior to the start of the survey, and was therefore past noncompliance. Findings include: 1. A facility reported incident, dated 7/31/24, indicated Resident B's son reported to the Executive Director (ED) two of her credit cards were fraudulently used by a person identified as CNA 1. The credit cards were canceled. The city police department was notified. CNA 1 was immediately suspended. A facility document, titled Allegation Investigation Form, dated 8/5/24, indicated CNA 1 was terminated on 8/5/24. Resident B's son reported to the ED there were suspicious charges on his mother's credit cards. The ED and the son called the credit card company to confirm the spelling of a person who had used the resident's credit card to order Door Dash. The son was prompted to look deeper into Resident B's credit card…

    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
Show the remaining 13 citations
  • Potential for harm · Ecited before2024-02-23 · 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

    A current policy, titled Pressure Injury Risk Assessment, not dated, indicated .the purpose of this procedure is to provide guidelines for the assessment and identification of resident at risk of developing pressure injuries .skin will be assessed for the presence of developing pressure injuries on a weekly basis or more frequently if indicated .nurses will conduct skin assessments at least weekly to identify changes .the following information should be recorded in the resident's medical record utilizing facility forms: type of assessment conducted (for example, admission assessment, weekly skin integrity tool) .the date and time and type of skin care provided, if appropriate .the name title (or initials) of the individual who conducted the assessment .any change in the resident's condition, if identified .the condition of the resident's skin (i.e. the size and location of any red or tender areas, (if identified) .initiation of a (pressure or non-pressure) form related to the type of alteration in skin if new skin alteration noted .documentation in medical record addressing MD…

    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 · E2024-02-23 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    3. During an observation, on 2/19/24 at 3:17 p.m., Resident 38 appeared calm and smiled frequently. During an observation, on 2/20/24 at 10:30 a.m., Resident 38 was calm and appeared comfortable while lying in bed after breakfast with his wife at his bedside. During an observation, on 2/22/24 at 9:42 a.m., Resident 38 was trying to eat breakfast with his eyes closed. Despite frequent cuing from staff, the resident kept closing his eyes again and was having difficulty eating his breakfast. The clinical record for Resident 38 was reviewed on 2/22/24 at 11:07 a.m. The diagnoses included, but were not limited to, Parkinson's disease with dyskinesia, dementia in other diseases with psychotic disturbance, hallucinations, and insomnia. A care plan, initiated 11/18/22, indicated the physician was to consider dosage reductions when clinically appropriate for the psychotropic medications of Resident 38. In a pharmacist's note to the attending physician/prescriber, dated 5/19/23, the prescriber disagreed to a gradual dose reduction for quetiapine for depression to 25 mg at bedtime with no…

    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 before2024-02-23 · 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, record review and interview, the facility failed to ensure the refrigerators and freezers were clean, food was sealed, labeled, and dated, and expired foods were discarded for 4 of 6 kitchens reviewed. (Kitchen 3, 4, 5 and 6) Findings include: 1. During an observation, on 2/19/24 at 1:10 p.m., the kitchen in Cottage 3 had the following: a. cooked cream of wheat brought in by a family which was dated 2/3/24. b. The freezer drawers were very dirty and had brown dried liquid spilled inside. c. The refrigerator in the kitchen had lime built up near the ice machine. During an interview, on 2/19/24 at 1:13 p.m., the Dietary Manager (DM) indicated the cooked cream of wheat should have been discarded after 3 days and the freezer looked like a soda exploded. During an interview, on 2/19/24 at 1:15 p.m., [NAME] 8 indicated the cream of wheat was frozen and was taken out when needed. 2. During an observation, on 2/21/24 at 10:37 a.m., the kitchen in Cottage 4 had the following: a. The refrigerator in the kitchen was dirty on the outside. The left side of the refrigerator…

    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 · Dcited before2024-02-23 · 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, interview and record review, the facility failed to ensure a resident was asked or instructed prior to repositioning for 1 of 1 resident reviewed for respect and dignity. (Resident 28) Finding includes: During an observation, on 2/20/24 at 10:30 a.m., Resident 28 was laying, in a recliner, with her head on the right armrest. The resident's chin was touching her chest. The resident was moving around in the recliner. During an observation, on 2/21/24 at 11:06 a.m., the resident was sleeping in a recliner in the lounge. There was no staff interaction with the resident. During an observation, on 2/22/24 at 9:48 a.m., the resident was laying, in her recliner, with her head on the right armrest. CNA 6 approached the resident and stood behind her. CNA 6 took both hands and placed them under the resident's arms. Without saying anything to the resident, CNA 6 lifted the resident up in the recliner. CNA 6 let go of the resident, she slid back down, and her head landed on the right armrest of the chair. CNA 6 walked away from the resident and left the resident with her…

    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 · Dcited before2024-02-23 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) were completed when new mental health diagnoses were added for 2 of 4 residents reviewed for PASARR. (Resident 5 and 36) Findings include: 1. The clinical record for Resident 5 was reviewed on 2/19/24 at 2:16 p.m. The diagnoses included, but were not limited to, Parkinson's disease, dementia without behavioral disturbance, atrial fibrillation, delusional disorder, and hallucinations. A PASARR level I, dated 5/25/17, indicated the resident had no mental health diagnosis and had no mental health medications. There were no known mental health behaviors which affected interpersonal interactions and no known mental health symptoms which affected the resident's ability to think through or complete tasks which the resident would be physically capable of completing. If changes occurred or new information refuted the findings, then a new screen must be submitted. The diagnoses of delusional disorder and hallucinations were added on 7/3/18. A care plan, dated 7/3/18,…

    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 · D2024-02-23 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a Level 1 Preadmission Screening and Resident Review (PASARR) prior to admission for 1 of 4 residents reviewed for PASARR. (Resident 3) Finding includes: The clinical record for Resident 3 was reviewed on 2/21/24 at 9:36 a.m. The diagnoses included, but were not limited to, vascular dementia, major depressive disorder, bipolar disorder, and anxiety. The resident was admitted on [DATE]. A medical diagnoses sheet indicated the resident had the following diagnoses: a. major depressive disorder on 1/3/22. b. anxiety disorder on 1/5/22. c. bipolar disorder on 1/5/22. There was no evidence a PASARR level 1 was completed on or prior to admission. During an interview, on 2/23/24 at 9:37 a.m., the Administrator indicated the PASARR was not completed, and it should have been. A current policy, titled admission Criteria, dated 5/20/20 and received from the Director of Nursing on 2/23/24 at 11:15 a.m., indicated .The Restoracy admits only residents whose…

    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 · D2024-02-23 · 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 provide quarterly care plan conferences and failed to include the use of a positioning cushion in the comprehensive care plan of 2 of 5 residents reviewed for care planning. (Resident 53 and 6) Findings include: 1. During an interview, on 2/20/24 at 10:25 a.m., Resident 53 indicated she did not remember attending any meetings about her care in a long time. During an interview, on 2/22/24 at 9:50 a.m., Resident 53 indicated she had not been invited or attended a care plan meeting in the past year. The clinical record for Resident 53 was reviewed on 2/22/24 at 10:48 A.M. The diagnoses included, but were not limited to, stage 4 pressure ulcer of left buttock, stage 4 pressure ulcer of right buttock, multiple sclerosis, type 2 diabetes mellitus, other chronic osteomyelitis, incomplete paraplegia, and benign neoplasm (mass) of spinal meninges. A Brief Interview of Mental Status (BIMS), dated 1/23/24, indicated Resident 53's cognition was intact. A social service note, dated 10/4/22 at 12:32 p.m., indicated a care…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-23 · 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, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living (ADL) care received the oral care recommendations from the Registered Dental Hygienist for 1 of 2 residents reviewed for ADL care. (Resident 5) Finding includes: During an observation, on 2/19/24 at 2:16 p.m., the resident had her mouth open, and no teeth were observed. The clinical record for Resident 5 was reviewed on 2/21/24 at 4:42 p.m. The diagnoses included, but were not limited to, dementia without behavioral disturbance, atrial fibrillation, rheumatoid arthritis, osteoporosis, and delusional disorder. A care plan, dated 7/25/17, indicated the resident had a potential risk for an activities of daily living (ADL) self-care performance deficit related to dementia and Parkinson's disease. The resident required assistance due to impaired coordination and balance. The goal was to maintain the current level of function with dressing and hygiene. The interventions included, but were not limited to, assist to the bathroom upon rising 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 · D2024-02-23 · 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, interview and record review, the facility failed to ensure cognitively stimulating activities were offered daily for 3 of 5 residents reviewed for activities. (Resident 23, 51 and 61) Findings include: 1. During an observation, on 2/20/24 at 10:46 a.m., the Activity Director entered Cottage 4's lounge carrying two children's books. The Activity Director informed the residents she was going to read a book about the month. The Activity Director read the book and left the cottage. During an observation, on 2/20/24 at 10:50 a.m., Resident 23 was sitting in a high back wheelchair in Cottage 4's lounge. The television was playing a musical and the volume was loud. The resident's head was tilted down. During an observation, on 2/21/24 at 10:59 a.m., the resident was sitting in Cottage 4's lounge with the television on. The head of the wheelchair was leaning back, and the resident was looking around. There were no activity staff in the cottage. During an observation, on 2/23/24 at 10:15 a.m., the resident was sitting in a high back wheelchair. The television was on,…

    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 · D2024-02-23 · tag F0691 — failed to provide colostomy / ostomy care — isolated
    Provide appropriate colostomy, urostomy, or ileostomy 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 who had a colostomy had specific direction for colostomy care for 1 of 1 resident reviewed for bowel and bladder. (Resident 25) Finding includes: The clinical record for Resident 25 was reviewed on 2/20/24 at 3:03 p.m. The diagnoses included, but were not limited to, colostomy. A care plan, dated 10/26/23, indicated the resident had an alteration in gastrointestinal status, and an ostomy related to colon cancer. Interventions included to assist the resident with ostomy care as needed, to give medications as ordered, to monitor and document side effects and the effectiveness of the medications, to obtain and monitor lab or diagnostic work as ordered, and to report the lab and diagnostic results to the physician and follow up as indicated. A physician's order, dated 12/23/23, indicated to change the colostomy bag every 3 days and as needed due to dislodgement. A physician's order, dated 12/25/23, indicated to check the colostomy bag for patency. There were no resident specific directions for the colostomy.…

    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 · D2024-02-23 · 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 interview and record review, the facility failed to recognize, provide interventions, and to notify the physician of a weight loss for 2 of 5 residents reviewed for nutrition. (Resident 51 and 5) Findings include: 1. The clinical record for Resident 51 was reviewed on 2/22/24 at 9:18 a.m. The diagnoses included, but were not limited to, diabetes mellitus, cardiomyopathy, congestive heart failure, hypertension, Alzheimer's disorder, and dementia. A care plan, dated as revised on 3/11/23, indicated the resident had a self-care performance deficit. The interventions included, but were not limited to, the resident required assistance from staff to eat. A care plan, dated as revised on 3/11/23, indicated the resident had diabetes mellitus. The interventions included, but were not limited to, a dietary consult for nutritional regimen and ongoing monitoring, to monitor, document and report compliance with diet and to document any problems, and to offer a substitute for foods not eaten. A physician's order, dated 3/12/23, indicated the resident was on a regular diet and received…

    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 · D2024-02-23 · tag F0882 — isolated
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    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 designated Infection Preventionist was onsite to work within the facility and completed the qualifying training or certification for 1 of 1 Infection Preventionist reviewed. (DON 2) Finding includes: During an interview, on 2/23/24 at 9:20 a.m., DON 1 indicated the DON of the Restoracy of Whitestown (DON 2) was overseeing the infection control program at the Carmel facility. DON 1 indicated DON 2 was not an employee of this facility. She provided a certificate of training to show DON 2 had completed Module 2 of the CDC Infection Preventionist training course. From the CDC website, https://www.cdc.gov/longtermcare/training.html, reviewed on 2/23/24 at 6:30 p.m., the CDC Infection Preventionist Training course was for individuals responsible for infection prevention and control programs in long term care and contained 23 modules which must be completed to obtain the certification. During an interview, on 2/23/24 at 11:35 a.m., DON 2 indicated she was currently acting as the Infection Preventionist for the Carmel…

    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 · D2023-08-03 · 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 a proper transfer technique was used during a transfer, resulting in an injury to 1 of 3 residents reviewed for accidents. (Resident B) Finding includes: During an interview, on 08/02/23 at 11:18 a.m., Resident B indicated the CNA was very strong, I don't think she realized how strong she was. She picked me up under my arms and pressed me to her very hard and plunked me down in the chair. This was all discolored and swollen (motioned to her left arm and shoulder). The resident then displayed her left arm, which was observed to have a red discolored area above her left elbow and under the upper left arm. There were red and purple discolorations with a yellow discoloration around the area. The record for Resident B was reviewed on 08/02/23 at 10:15 a.m. Diagnoses included, but were not limited to, unspecified fall, displaced trimalleolar fracture of unspecified lower leg, subsequent encounter for closed fracture with routine healing,…

    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.

Who owns this facility

Owner / managerTypeRoleSince
COUCH, GINAIndividualCONTRACTED MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2019
EUSON, MATTHEWIndividualCONTRACTED MANAGING EMPLOYEEsince 12/05/2022
LINDSAY, BRYANIndividualCONTRACTED MANAGING EMPLOYEEsince 12/05/2022
GREENWOOD, ANDREWIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 12/22/2020
HORNER, JOHNIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 01/01/2019
BEATY, JEFFIndividualCORPORATE DIRECTORsince 12/22/2020
CALDWELL, DANAIndividualCORPORATE DIRECTORsince 12/22/2020
CARTER, DOUGLASIndividualCORPORATE DIRECTORsince 12/22/2020
COFFIN, JOHNIndividualCORPORATE DIRECTORsince 12/22/2020
JONES, CURTISIndividualCORPORATE DIRECTORsince 12/22/2020
SANDMAN, JANIndividualCORPORATE DIRECTORsince 12/22/2020
TANDY, SHERRIIndividualCORPORATE DIRECTORsince 12/22/2020
EUSON LINDSAY LEGACY, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 12/05/2022
GREEN HOUSE SENIOR LIVING L.L.C.OrganizationOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2019

CMS files one row per role, so the 17 rows in the source record cover these 14 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.

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.

$10.1M
Net patient revenuemost recent cost report
+28.9%
Operating marginrevenue minus expenses
$144K
Related-party expense2% of expenses
Who pays — share of resident-days
Medicaid 48%Medicare 7%Other / private 45%

This home reported $144K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$298per resident / day
operating cost
$9,056per month
≈ monthly operating cost
$419per 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 155846. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-20, 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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