Addison Pointe Health & Rehabilitation Center
780 Dickinson Road, Chesterton, IN 46304 · Non profit - Corporation · 100 certified beds · (219) 921-2200 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- about 26% 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 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, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 4.1% | 11.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.5% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.4% | 0.9% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.0% | 1.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 18.9% | 25.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.6% | 3.9% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 3.5% | 11.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 18.2% | 23.5% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 98.7% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.2% | 3.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 18.9% | 23.3% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.7% | 13.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.3% | 1.2% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 19.1% | 79.0% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 22.4% | 22.2% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 14.1% | 10.8% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.48 | 1.61 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.89 | 1.44 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
68.4% 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 342 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 71.4% 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 140 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 0.31 therapist hours per resident per day in 2026Q1 — more than 50% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 68.4%CMS range 63.3–72.7 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.1%CMS range 8.8–14.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 71.4% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 62.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 67.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 97.1% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.4%CMS range 3.6–8.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.90 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 100 beds and averages 92.5 residents a day — about 92% occupied, or roughly 8 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.54 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.79 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.04 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.00 hrs/resident/day on weekends vs 3.76 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.91 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 34% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.
- Actual harm · G2025-03-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a resident, dependent on staff for transferring from the chair to bed, had received adequate assistance and supervision to prevent accidents related to staff not following the manufacture's manual regarding keeping the legs of the lift at their maximum opened position before lifting a resident during a mechanical lift transfer for 1 of 2 residents reviewed for accidents. (Resident 21) This deficient practice resulted in the resident falling and receiving a fracture to her left upper arm. The deficient practice was corrected on 10/16/24, prior to the start of the survey, and was therefore past noncompliance. The facility identified the concern, completed a house wide sweep of the Hoyer lifts (a mechanical lift) and Hoyer slings, an inservice was held related to transfer techniques, two person staff assist while using the Hoyer lift, and leg of the base in their widest opened position, and return demonstration by staff was observed, and audits related to the use of the Hoyer lift were completed. Finding includes:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-05-07 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure bruises were assessed and monitored for 2 of 3 residents reviewed for non-pressure related skin conditions, blood pressure medications were administered within parameters for 2 of 3 residents reviewed for medications with parameters, and an assessment was documented prior to and after an outpatient procedure for 1 of 3 residents reviewed for falls. (Residents 77, 48, 42, and 11)Findings include:1. The record for Resident 77 was reviewed on 5/4/26 at 1:34 p.m. Diagnoses included but were not limited to, stroke, dementia, fracture of right talus (ankle), major depressive disorder, and osteoarthritis of right and left knees. The Quarterly Minimum Data Set (MDS) assessment, dated 4/7/26, indicated the resident was moderately impaired for daily decision making. The resident had an impairment in range of motion to one side of his lower extremities and needed partial to moderate assist with transfers. An Outpatient Discharge Instruction sheet, dated 4/10/26, indicated the resident had a post medial branch…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-05-07 · tag F0761 — failed to label and store drugs safely — patternEnsure 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, record review, and interview, the facility failed to ensure medications were stored appropriately related to nystatin powder, insulin pens were not used past the expiration date, and over the counter medications were labeled correctly for 2 of 2 residents observed with medications in their rooms and for 2 of 4 medication carts observed. (Residents 42 and 9, the 100 hall and 400 hall medication carts)Findings include:1. During a random observation on [DATE] at 9:30 a.m., Resident 42 was observed in bed. At that time, there was a small plastic medication cup filled to the top of white powder on her dresser. During an interview at that time, the resident indicated the nurse had brought some Nystatin powder for her rash under her breasts and left it there so she could apply it herself. The record for Resident 42 was reviewed on [DATE] at 1:21 p.m. Diagnoses included, but were not limited to, anxiety disorder, major depressive disorder, type 2 diabetes, heart failure, high blood pressure, 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.
- Potential for harm · D2026-05-07 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to maintain a resident's dignity related to checking a resident's blood sugar and announcing the result in a common area for 1 of 2 residents reviewed for dignity. (Resident 97)Finding includes:During an observation on 5/1/26 at 11:21 a.m., RN 1 was preparing to check Resident 97's blood sugar. The resident was sitting in her wheelchair in the day room along with two other residents and a visitor. RN 1 approached the resident, and told her she was going to check her blood sugar. She stuck the resident's finger, checked her blood sugar, and announced the result loudly. RN 1 did not ask the resident permission to check her blood sugar in the common area with others present. During an interview on 5/1/26 at 11:43 a.m., Unit Manager 1 indicated the resident was alert and oriented, and new to the facility. They were working on a care plan that indicated the resident was ok with having her blood sugar checked in common areas. When informed that RN 1 did not ask the resident's permission and that she announced the results loudly with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 residents who were dependent on staff for Activities of Daily Living (ADLs) received the care and assistance needed related to trimming their fingernails for 2 of 7 residents reviewed for ADLs. (Residents 7 and 57)Findings include: 1. On 4/29/26 at 10:37 a.m., and again on 5/4/26 at 1:10 p.m., Resident 7 was observed lying in bed. The resident's fingernails were long, thick, and yellowed. The resident indicated she would like someone to cut her fingernails but had been told they could not cut them because she had a fungus in them. Record review for Resident 7 was completed on 5/4/26 at 9:47 a.m. Diagnoses included, but were not limited to, stroke, hemiplegia (paralysis on one side of the body) and depression. The Annual Minimum Data Set (MDS) assessment, dated 3/10/26, indicated the resident was cognitively intact. The resident had an impairment on one side of her upper extremities for a functional limitation in range of motion. The resident required substantial maximal assistance for personal hygiene.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-07 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to provide activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 1 of 2 residents reviewed for activities. (Resident 22)Finding includes:During random observations at the following dates and times, Resident 22 was observed lying in bed, the room quiet without television, music, or other stimulation: 4/29/26 at 11:31 a.m., 4/30/26 at 10:16 a.m. and 3:16 p.m., 5/1/26 at 10:13 a.m. and 2:53 p.m., 5/4/26 at 9:51 a.m., and 5/6/26 at 11:20 a.m. On 5/1/26 at 2:15 p.m., an activities event with live music was observed in the main dining room. Resident 22 remained in his quiet room, awake in bed.The record for Resident 22 was reviewed on 5/4/26 at 10:14 a.m. Diagnoses included, but were not limited to, Parkinson's Disease and cerebrovascular disease.The Quarterly Minimum Data Set (MDS) assessment, dated 2/10/26, indicated the resident had moderate cognitive impairment and was dependent in ADLs and transfers.An Activities Care Plan, revised 4/27/26,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-07 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to provide oxygen at the correct flow rate and with protective padding as ordered for 1 of 1 resident reviewed for respiratory care. (Resident 22)Finding includes:During random observations on 4/30/2026 at 10:16 a.m. and 2:07 p.m., and 5/4/2026 at 9:50 a.m., Resident 22 was resting in bed. Oxygen was in use via a nasal cannula (small, soft prongs that go into the nostrils) at 3.5 lpm (liters per minute). There was no padding in place on the cannula tubing. The record for Resident 22 was reviewed on 5/4/26 at 10:14 a.m. Diagnoses included, but were not limited to, Parkinson's Disease, pneumonia, chronic respiratory failure, and dependence on supplemental oxygen. The Quarterly Minimum Data Set (MDS) assessment, dated 2/10/26, indicated the resident had moderate cognitive impairment and was dependent for activities of daily living (ADLs). A Physician's Order, dated 3/24/2026, indicated oxygen at 4 lpm per nasal cannula, continuously. A Physician's Order, dated 3/26/2026, indicated padding to oxygen tubing, ensure…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-07 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and a system of monitoring to improve resident outcomes and reduce antibiotic resistance related to a practitioner prescribing antibiotics for not true infections based on the McGeer Criteria (standardized definitions used for urinary tract infection (UTI) surveillance in long-term care, requiring both specific symptoms and microbiologic evidence) for 2 of 3 residents reviewed for urinary tract infections. (Residents 42 & 5)Findings include:1. During an interview on 4/30/26 at 9:50 a.m., Resident 42 indicated she has had frequent Urinary Tract Infections (UTI's) and as soon as the antibiotic was completed, the symptoms start again. During an interview on 5/6/26 at 9:30 a.m., the resident indicated she had seen an Urologist and had a procedure, however, she got sick with COVID and has not had the follow up appointment. She still would like to see this physician. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-03-21 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to maintain the kitchen in a sanitary manner and in good repair related to lack of monitoring of freezer, refrigerator, and dishwasher temperatures and food not labeled and dated, for 1 of 1 kitchen. This had the potential to affect 86 of 87 residents who resided in the facility and received food from the kitchen. Findings include: During the Initial Kitchen Sanitation Tour on 3/17/25 at 8:47 a.m., with the Kitchen Manager, the following was observed: 1. There was no thermometer in the walk-in freezer. 2. There was no thermometer in the reach-in cooler. 3. The dishwasher temperature log was already filled out for breakfast, lunch and dinner time temperature checks for 3/17/25. 4. There was an unlabeled and undated tray of pre-filled cups of juice in the walk-in refrigerator. 5. The following items were found undated in the walk-in freezer: a bag of cookies, a bag of bread, a package of unidentified meat, a container of ice cream, a bag of ground sausage, and an open box of tropical freezes. 6. The following…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-21 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to implement a resident's care plan related to positioning for 1 of 3 residents reviewed for limited range of motion (ROM). (Resident 33) Finding includes: During an observation on 3/17/25 at 10:00 a.m., Resident 33 was observed resting in bed. He had limited movement of his left arm and his left hand appeared contracted (unable to open). At that time, the resident indicated he could only open his left hand if he used his right hand to open it since he had had a stroke. There were no rails or bars present on the bed. During the following observations on 3/18/25 at 9:54 a.m., 3/19/25 at 10:37 a.m. and 3/20/25 at 11:00 a.m., the resident was lying in bed and there were no rails or bars present on his bed. The resident's record was reviewed on 3/20/25 at 10:06 a.m. Diagnoses included, but were not limited to, disorders of the brain, vascular dementia, and chronic heart failure. The 2/24/25 Quarterly Minimum Data Set (MDS) assessment, indicated the resident had severe cognitive impairment and was dependent on staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-21 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents, related to turning and repositioning for 1 of 2 residents reviewed for ADLs. (Resident 33) Finding includes: During an observation on 3/17/25 at 10:00 a.m., Resident 33 was observed resting in bed, lying on his back. He had limited movement of his left arm and his left hand appeared contracted (unable to open). During the following observations on 3/18/25 at 9:54 a.m. and 2:14 p.m., 3/19/25 at 10:37 a.m., and 3/20/25 at 9:35 a.m. and 11:00 a.m., the resident was lying in bed on his back. The resident's record was reviewed on 3/20/25 at 10:06 a.m. Diagnoses included, but were not limited to, disorders of the brain, vascular dementia, and chronic heart failure. The 2/24/25 Quarterly Minimum Data Set (MDS) assessment, indicated the resident had severe cognitive impairment, and was dependent in ADLs (activities of daily living) and transfers. A review of a Care Plan, revised on 9/4/24, indicated the resident had hemiplegia (paralysis…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 14 citations
- Potential for harm · Dcited before2025-03-21 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure areas of discoloration were assessed and monitored for 2 of 2 residents reviewed for non-pressure skin conditions .(Residents 62 and 44) Findings include: 1. On 3/17/25 at 9:47 a.m., Resident 62 was observed with two small areas of reddish/purple discoloration to his right elbow. On 3/18/25 at 2:03 p.m. and 3/19/25 at 10:01 a.m., the discoloration remained to the resident's elbow. The record for Resident 62 was reviewed on 3/18/25 at 2:55 p.m. Diagnoses included, but were not limited to, Parkinson's disease, anemia, and dementia without behavior disturbance. The Quarterly Minimum Data Set (MDS) assessment, dated 3/5/25, indicated the resident was moderately impaired for daily decision making and had no skin issues. The Weekly Skin Observation Assessment, dated 3/17/25 at 3:06 a.m., indicated the resident had no bruising. The March 2025 Physician's Order Summary (POS), indicated there were no orders to monitor the areas of discoloration to the resident's right elbow. During an interview on 3/19/25 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-21 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure pressure reduction devices were in use for a resident with a pressure ulcer for 1 of 2 residents reviewed for pressure ulcers. (Resident 66) Finding includes: On 3/19/25 at 1:17 p.m. and 3:22 p.m., Resident 66 was observed in her room in bed. Her heel boots (a pressure reducing device) were observed on the chair next to the resident's bed. The resident's feet were not elevated while she was lying in bed. On 3/20/25 at 1:44 p.m. and 2:30 p.m., the resident was again observed in her bed. Her heel boots were in the chair, next to her bed and her feet were not elevated. The record for Resident 66 was reviewed on 3/19/25 at 10:07 a.m. Diagnoses included, but were not limited to, Alzheimer's disease and dementia without behavior disturbance. The admission Minimum Data Set (MDS) assessment, dated 1/10/25, indicated the resident was severely impaired for daily decision making, was dependent on staff for rolling left and right and for chair to bed transfers. The resident was not identified as having any…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure each resident requiring respiratory care received necessary services related to changing oxygen tubing for 1 of 4 residents reviewed for respiratory services. (Resident 44) Finding includes: During a random observation on 3/17/25 at 10:35 a.m., Resident 44 was observed sitting in her wheelchair. She was wearing a nasal cannula (a pronged tube that delivers oxygen through the nostrils), connected to a portable oxygen tank. The oxygen tubing was not dated. On 3/18/25 at 9:20 a.m., the resident was observed wearing her oxygen cannula. The oxygen tubing was not dated. The resident's record was reviewed on 3/18/25 at 2:17 p.m. Diagnoses included, but were not limited to, post-hip replacement, dementia, and muscle weakness. The 2/27/25 admission Minimum Data Set (MDS) assessment, indicated the resident had severe cognitive impairment and was dependent in Activities of Daily Living (ADLs) and transfers. A Physician's Order, dated 2/25/25, indicated oxygen at 2 lpm (liters per minute) continuous, may titrate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-31 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
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 file and resolve a resident grievance for a missing wheelchair for 1 of 1 resident reviewed for grievances. (Resident M) Finding includes: On 7/30/24 at 1:20 p.m., Resident M was observed awake, sitting up in bed and talking with his son. Resident M indicated he was unhappy with how the facility handled his missing wheelchair. During an interview at that time, Resident M indicated he had been missing a personal wheelchair since before Father's Day. The facility was aware his wheelchair was missing and he was told they would get him fitted for another wheelchair. The resident's son talked with the the therapy director a couple weeks ago, and it was communicated that the resident would be measured for a new wheelchair the following day. They were unsure if the facility had a grievance on file for their concern. Resident M's record was reviewed on 7/30/24 at 3:59 p.m. Diagnoses included, but were not limited to, heart failure, chronic pain, arthritis, insomnia (difficulty sleeping), gout (excess of uric acid in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-31 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff members when providing care to a resident who was in Enhanced Barrier Precautions (EBP) for 1 of 3 residents reviewed for infection control isolation practices. (RN 1, CNA 1, and Resident E). Finding includes: During an observation on 7/30/24 at 11:45 a.m., Resident E was observed lying in bed in the room. There was a sign on the door that indicated the resident was in EBP and PPE of a gown and gloves was to be worn during high contact activities. CNA 1 brought a Hoyer (mechanical) lift to Resident E's room and attempted to transfer Resident E. CNA 1 then asked RN 1 to assist her in the transfer of Resident E. RN 1 sanitized her hands and entered Resident E's room, where she assisted with the Hoyer lift transfer. Both CNA 1 and RN 1 were not wearing the proper PPE which included gowns and gloves. During an interview with RN 1 on 7/30/24 at 11:50 a.m., she indicated the staff does not apply PPE unless they were actually touching the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-23 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure residents had Physician's Orders to administer their own medications, as well as a self-administration of medication assessment, for 1 of 1 residents reviewed for self-administration of medication. (Resident 6) Finding includes: During a random observation on 2/19/24 at 11:22 a.m., a container of Nystatin cream (an antifungal medication) was on Resident 6's bedside table. During a random observation on 2/21/24 at 10:30 a.m., two containers of Biofreeze (a topical pain reliever) were on the resident's television stand. Resident 6's record was reviewed on 2/21/24 at 11:26 a.m. Diagnoses included, but were not limited to, type 2 diabetes, vascular dementia, hemiplegia (muscle paralysis) and hemiparesis (muscle weakness). The Annual Minimum Data Set (MDS) assessment, dated 2/12/24, indicated the resident was cognitively intact for daily decision making. There was no Care Plan for the resident to self-administer her medications. Physician's Orders, dated 4/13/23 and listed as current on the February 2024…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-23 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure areas of bruising were assessed and monitored, and treatment orders were obtained timely for a resident with a skin tear, for 2 of 2 residents reviewed for skin conditions non-pressure related. (Residents 66 and 79) Findings include: 1. During a random observation on 2/20/24 at 9:48 a.m., Resident 66 had two areas of reddish/purple discoloration to his right wrist. During a random observation on 2/23/24 at 11:03 a.m., the discoloration remained to the resident's right wrist. The record for Resident 66 was reviewed on 2/22/24 at 2:05 p.m. Diagnoses included, but were not limited to, Parkinson's disease, dementia without behavior disturbance, and atherosclerotic heart disease. The Quarterly Minimum Data Set (MDS) assessment, dated 2/14/24, indicated the resident was cognitively intact. He required extensive assistance with bed mobility and was dependent on staff for transfers. A Physician's Order, dated 1/4/24, indicated the resident was to have skin sleeves or a long sleeve shirt on when out of bed as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-23 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure finger orthotics were available and worn as ordered, for 1 of 1 residents reviewed for range of motion. (Resident 12) Finding includes: On 2/19/24 at 3:09 p.m., Resident 12 was observed seated in her recliner in her room. A finger splint was observed to her right 4th finger with clear tape wrapped around it. During an interview at that time, Resident 12 indicated she wore the splint to her 4th finger for arthritis and kept it on at all times. Staff did not assist her with taking it off or tell her if/when she should take it off. On 2/21/24 at 10:26 a.m., the resident was observed seated in her recliner in her room. A finger splint was observed on her right 4th finger with clear tape wrapped around it. During an interview at that time, Resident 12 indicated she used to have a splint for her left pinky finger as well, but it had been missing for a while and she didn't know where it was. The record for Resident 12 was reviewed on 2/21/24 at 1:21 p.m. Diagnoses included, but were not limited to,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-23 · tag F0698 — failed to provide proper dialysis care — isolatedProvide 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 observation, record review, and interview, the facility failed to provide the necessary care and services for residents who received hemodialysis, related to not monitoring the dialysis access site, for 1 of 1 residents reviewed for dialysis. (Resident 199) Finding includes: On 2/20/24 at 9:22 a.m., Resident 199 was observed lying in bed in her room. During an interview at that time, Resident 199 indicated she went to dialysis on Mondays, Wednesdays, and Fridays. She recently had surgery on her left arm to fix her fistula, so they were not currently using that access as they were waiting for it to heal. She had a catheter to her chest that she used for dialysis. She indicated the facility would check the catheter sometimes but mostly the dialysis center would monitor it. The record for Resident 199 was reviewed on 2/22/24 at 2:32 p.m. Diagnoses included, but were not limited to, end stage renal disease, congestive heart failure, and hypertension. The admission Minimum Data Set (MDS) assessment, dated 2/18/24, indicated the resident was cognitively intact 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.
- Potential for harm · D2024-02-23 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure clinical records were complete and accurately documented, related to meal consumption, for 1 of 3 residents reviewed for nutrition. (Resident 46) Finding includes: The record for Resident 46 was reviewed on 2/21/24 at 2:26 p.m. Diagnoses included, but were not limited to, stroke, dementia without behavior disturbance, gastroesophageal reflux disease (GERD), and protein calorie malnutrition. The Quarterly Minimum Data Set (MDS) assessment, dated 11/23/23, indicated the resident was moderately impaired for daily decision making and he required supervision with eating. The resident had sustained a weight loss during the assessment reference period. A Care Plan, reviewed and revised on 2/13/24, indicated the resident required a therapeutic diet. Interventions included, but were not limited to, meal intakes were to be documented daily. The Food Consumption sheets for the month of February 2024, indicated there was no daily meal consumption documented between 2/1-2/14/24. During an interview on 2/23/24 at 10:14 a.m., the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-18 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure a dependent resident received timely ADL (activities of daily living) assistance needed related to incontinence care for 1 of 1 random observations. (Resident D) Finding includes: On 9/18/23 at 9:42 a.m., there was a strong bowel movement (BM) odor noted when walking in the hall near the 300 unit nurses' station. Across from the nurses' station there was a television area where 3 residents were seated in their wheelchairs. Upon entering the television area, the BM odor was noted to be very strong. Nurse 1 was observed seated at the nurses' station. At 10:05, Resident D was observed leaning forward in her wheelchair. There was BM observed coming out of her pants and up her back. At 10:14 a.m. and 10:18 a.m., the Director of Nursing (DON) was observed walking past the TV area. At 10:39 a.m., Nurse 1 was standing at the medication cart, which was closer to the TV area. At 10:43 a.m., a staff member brought another resident into the TV area and then left. Several staff were observed walking past the TV…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-08-29 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview the facility failed to ensure activities were provided as scheduled and failed to provide routine outings as scheduled which had the potential to effect all residents who wanted to participate in activities. The facility also failed to ensure an annual activity assessment was completed for 1 of 3 residents reviewed for activities. (Resident C) Findings include: 1. On 8/29/23, between 9:33 a.m. and 9:52 a.m., the facility was observed for the scheduled activity of exercise. The main lobby and activity room was empty, the main dining room was empty. A staff member indicated SDR was the Satellite Dining Room, and was located between the 300 and 400 halls and that was where the exercise took place. The SDR was also empty upon observation. On 8/29/23 at 10:00 a.m., the activity room had three orientees in it. They indicated they did not know where activity staff were. All dining rooms were empty. A staff member indicated if the activity room was empty, the activity should be taking place in the dining room on the 200 unit. The 200 unit…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-29 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to provide reasonable accommodation of needs related to not transporting a resident to outings due to footrests on her wheelchair for 1 of 3 residents reviewed for activities. (Resident D) Finding includes: Resident D's record was reviewed on 8/29/23 at 9:17 a.m. Diagnoses included, but were not limited to hemiplegia and hemiparesis (one sided weakness and paralysis) following a CVA (stroke), and Diabetes Mellitus. The Quarterly Minimum Data Set (MDS) assessment, dated 8/18/23, indicated she was cognitively intact and required extensive 2 staff assist for bed mobility and was dependent on 2 staff for transfers. Interview with Resident D on 8/29/23 at 8:53 a.m., indicated the facility rarely took them for outings. She indicated there was always an excuse that the bus was broken, or needed for an appointment or too hot. She has canceled doctor appointments to go on outings, then they don't go. Interview with the Activity Director on 8/29/23 at 12:41 p.m., indicated the resident had a wheelchair with footrests. They were afraid…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-29 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to provide a diet as requested per resident preference related to fluid restriction and diet desserts for 1 of 3 residents reviewed for dietary services. (Resident C) Finding includes: On 8/29/23 at 11:55 a.m., Resident C was observed in her room with her lunch tray in front of her. She had a Salisbury steak, mixed vegetables, garlic bread, an 8 ounce glass of water, a 4 ounce glass of juice and a half cup serving of sherbet. She indicated the meal was not what she had ordered. She could not eat processed meat on a renal diet and was on fluid restrictions, and had ordered a chef salad or fruit plate. The tray ticket on the lunch tray indicated a regular renal diet, regular texture and an Alert noted 1500 ml fluid restriction and diet desserts. The Notes indicated 1-8 ounce beverage only. Resident C's record was reviewed on 8/29/23 at 10:30 a.m. Diagnoses included, but were not limited to, Diabetes Mellitus, chronic respiratory failure and dependence on renal dialysis. The Annual Minimum Data Set assessment,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to TLC MANAGEMENT — 20 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.8 | -0.8 vs chain |
| Health inspection | 2 of 5 | 3.3 | -1.3 vs chain |
| Staffing | 4 of 5 | 3.5 | +0.5 vs chain |
| Quality measures | 5 of 5 | 4.7 | +0.3 vs chain |
The other 19 homes this chain runs (chain average 3.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| RIVERVIEW HOSPITAL | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 08/01/2014 |
| FRIEND, JAYNA | Individual | CORPORATE OFFICER | — | since 08/01/2014 |
| HYATT, DAVID | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 03/29/2023 |
| CHESTERTON HEALTHCARE OPERATIONS COMPANY LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/26/2026 |
| TENDER LOVING CARE MANAGEMENT INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/24/2025 |
| AGARWAL, BIKASH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2025 |
| WHITEHEAD, CAREL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2025 |
| GIBSON, CULLEN | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 07/24/2025 |
| OTT, DWIGHT | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 07/24/2025 |
| OTT, GARY | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 07/24/2025 |
| OTT, RYAN | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 07/24/2025 |
| CHESTERTON HEALTH CARE PROPERTIES LLC | Organization | ADP OF THE SNF | — | since 08/01/2014 |
CMS files one row per role, so the 17 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.
4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $3.4M paid to related parties — landlords or management companies under common ownership — equal to about 26% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Indiana Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 155805. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-07, 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 →
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