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Vermillion Convalescent Center

1705 S Main St, Clinton, IN 47842 · Government - County · 100 certified beds · (765) 832-3573 Medicare & Medicaid certified

Call the home — (765) 832-3573 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Aug 2025
Insights

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

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Aug 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (2/5)
  • about 22% 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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1361 Fort Harrison Rd · (812) 235-4000 · Call to confirm hours
Pharmacy
924 Western Ave · (765) 832-2431 · Call to confirm hours
Grocery
1047 Western Ave · (765) 832-3517 · Call to confirm hours
Park
Bark Park Clinton · 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 2 of 5
Long-stay residentspeople who live here 1 of 5
Short-stay residentsrehab / post-hospital 2 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased28.2%11.0%15.4%worse
Long-stay residents who lose too much weight7.9%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.8%0.4%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection4.0%1.1%2.0%worse
Long-stay residents with depressive symptoms33.8%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 injury5.7%3.9%3.3%worse
Long-stay residents whose ability to walk worsened19.1%11.9%16.1%worse
Long-stay residents on antianxiety or hypnotic medication12.6%23.5%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%95.4%95.3%typical
Long-stay residents with pressure ulcers3.2%3.6%4.7%better
Long-stay residents with worsening bladder/bowel control25.8%23.3%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table14.4%13.6%17.1%better
Short-stay residents who newly got an antipsychotic medication1.5%1.2%1.4%typical
Short-stay residents given the seasonal flu vaccine100.0%79.0%79.4%better
Short-stay residents rehospitalized after admission28.4%22.2%22.6%worse
Short-stay residents with an outpatient ER visit11.9%10.8%12.0%typical
Long-stay hospitalizations per 1,000 resident days2.041.611.67worse
Long-stay outpatient ER visits per 1,000 resident days2.041.441.80worse

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.

50.8% 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 47 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.8%U.S. median 51.5%
Got home and stayed home
10.3%U.S. median 10.7%
Went back to hospital
63.6%U.S. median 56.6%
Met the expected recovery
0.26U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.08hours / resident / day
Speech therapy

Met the expected recovery: 63.6% 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 33 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 0.26 therapist hours per resident per day in 2026Q1 — more than 37% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 13% 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 SNF50.8%CMS range 39.5–63.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.3%CMS range 7.0–14.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge63.6%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 discharge69.7%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 discharge63.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay2.0%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 worsened14.3%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 hospitalization6.6%CMS range 3.3–11.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.351.02Oct 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

0.31
RN hours/ resident / day
0.56
LPN hours/ resident / day
1.89
Aide hours/ resident / day
2.76
Total nurse hours/ resident / day
0.25
RN hoursweekends
46.8%
Total nursing turnover
37.5%
RN turnover

How full it usually is: this home is certified for 100 beds and averages 78.6 residents a day — about 79% occupied, or roughly 21 beds typically open. It usually has some room. 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 2.76 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.31 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.89 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.40 hrs/resident/day on weekends vs 2.90 on weekdays — 17% thinner on weekends. RN hours go from 0.34 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 47% is about the same as 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

11
deficiencies at the latest standard inspection (2025-08-19)
5
at the previous standard inspection (2024-07-22)

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.

22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.

  • Potential for harm · Dcited before2026-06-18 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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 the resident was assessed and a physician order was obtained prior to utilizing an audible bed and chair alarm for 1 of 2 residents reviewed for falls (Resident B). Findings include:On 6/17/26 at 12:35 p.m. during an initial observation and interview, Resident B sat in the main dining room with her husband. She was alert with some confusion noted during the interview. The resident indicated she had some falls but had not been hurt any of the times she fell. The resident was sitting in her wheelchair on a black air filled cushion and an incontinent pad. No anti-skid material was observed in the wheelchair. Observed anti-tip bars to the lower bottom of the wheelchair. The bars were upside down. No alarm observed on the chair. The husband indicated there was an alarm on the bed and usually there was a chair alarm and indicated the staff must have forgotten to put the chair alarm back on when they had gotten her up earlier. On 6/17 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · E2025-08-19 · 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

    A. Based on observation, record review, and interview, the facility failed to ensure hand hygiene was performed during the medication pass and appropriate infection control techniques were utilized for 5 of 5 residents medication passes observed (Residents 33, 36, 48, 28, and 62). B. Based on observation, record review, and interview, the facility failed to ensure enhanced barrier precautions (EBP) (use of gowns and gloves during high-contact resident care activities) were followed for 2 of 5 residents' medication passes observed (Residents 33 and 10). Findings include:A. On 8/15/25 at 8:06 a.m., Registered Nurse (RN) 22 was observed preparing medication for Resident 33. During the preparation, one of the pills fell onto the medication cart. RN 22 picked up the pill bare-handed and placed it into the medication cup. RN 22 entered Resident 33's room, put on gloves, and completed the resident's accu-check (finger stick to check blood sugar). The resident's blood sugar was 69 milligrams (mg)/deciliter (dl). RN 22 did not perform hand hygiene before or after the accu-check. At the same…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-19 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure informed consent documents for psychotropic medications had been obtained, for 2 of 5 residents reviewed for unnecessary medications (Residents 73 and 1). Findings include: 1.Resident 73's record was reviewed on 8/14/25 at 11:43 a.m. The profile indicated the resident's diagnoses included, but were not limited to, unspecified dementia, severe, with agitation (dementia that severely impacts daily life and functioning with agitation), Alzheimer's disease (a progressive brain disorder that gradually impairs memory, thinking, and reasoning skills, eventually affecting the ability to perform simple tasks), anxiety disorder (a mental health condition characterized by excessive and persistent worry, fear, and nervousness that interferes with daily life), and irritability and anger. A significant change Minimum Data Set (MDS) assessment, dated 7/15/25, indicated the resident had severe cognitive deficit, physical behavioral symptoms directed towards…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-19 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    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 the call light was within the reach of the residents for 2 of 24 residents reviewed for call light placement (Residents 25 and 23).Findings include:1. On 8/14/2025 at 1:32 p.m., during initial routine observation, observed Resident 25 sleeping in bed. Call light was not within reach of the resident. Unable to locate the call light. On 8/15/2025 at 1:34 p.m., observed Resident 25 sitting in a recliner in her room. The call light was attached to the middle of the curtain within the folds of the curtain residents bed at the foot of the bed. The resident was unable to answer any interview questions. On 8/18/25 at 10:40 a.m., during an interview Certified Nurse Aide (CNA) 6 indicated she makes sure the call light was within reach of residents even if the resident did not use the call light. On 8/18/25 at 11:50 a.m., during an interview Certified Nurse Aide (CNA) 8 indicated she would make sure the call light was within reach of the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-19 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    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 was provided showers as preferred for 1 of 1 residents reviewed for choices (Resident 51). Findings include: During an interview, on 8/13/25 at 3:28 p.m., Resident 51 indicated she thought that the staff often forgot about her, and she did not receive her showers as scheduled. She was unable to recall when her last shower was. Resident 51's record was reviewed on 8/15/25 at 10:10 a.m. A significant change Minimum Data Set (MDS) assessment, dated 8/6/25, indicated the resident was cognitively intact and required moderate assistance with showers and toileting. A care plan, dated 5/15/25, indicated the resident requires assistance from 1-2 staff in preforming activities of daily living (ADL's) related to shortness of breath, pain, and incontinence. Interventions included, but were not limited to, offer bathing choices, showers/baths per schedule and more frequently if requested and as needed, and nail care as needed. Review of shower schedule indicated Resident 51 was to receive her showers on Tuesday 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-19 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    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 protect the resident's right to be free from physical and verbal abuse for 1 of 2 residents reviewed for abuse (Resident 1).Findings include:On 8/18/25 at 9:36 a.m., an allegation of abuse was reported by the Regional Nurse Consultant (RNC). Review of facility reported incident indicated an allegation of abuse was reported to IDOH on 8/16/25 at 8:40 a.m., by the facility Administrator. The report indicated Certified Nursing Aides (CNAs) 8 and 12 were caring for Resident 1's roommate in the first bed. Both CNAs saw CNA 11 at the bedside of Resident 1 in the same room, pulling Resident 1's hand off of the side rail, pushing the resident's arm into his stomach, speaking abruptly to the resident, and using profanity. The CNAs 8 and 12 immediately intervened and prevented further interaction between CNA 11 and the resident. A skin tear was noted to Resident 1's right arm. The CNA 11 responded that it was there last night and she didn't do it. However, one…

    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 · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-19 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    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 the administrator was notified immediately of an allegation of abuse of 1 of 2 residents reviewed for abuse (Resident 1). Findings include:On 8/18/25 at 9:36 a.m., an allegation of abuse was reported by the Regional Nurse Consultant (RNC). Review of facility reported incident indicated an allegation of abuse was reported to IDOH on 8/16/25 at 8:40 a.m., by the facility Administrator. The report indicated Certified Nursing Aides (CNAs) 8 and 12 were caring for Resident 1's roommate in the first bed. Both CNAs saw CNA 11 at the bedside of Resident 1 in the same room, pulling Resident 1's hand off of the side rail, pushing the resident's arm into his stomach, speaking abruptly to the resident, and using profanity. The CNAs 8 and 12 immediately intervened and prevented further interaction between CNA 11 and the resident. A skin tear was noted to Resident 1's right arm. The CNA 11 responded that it was there last night and she didn't do it. However,…

    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 · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-19 · 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 fingernail care was provided for 1 of 24 residents reviewed for activities of daily living (ADLs) (Resident 23). Findings include: On 8/13/25 at 11:13 a.m., Resident 23's fingernails on the right hand were observed to be long and jagged with dark debris underneath them. On 8/14/25 at 10:12 a.m., Resident 23 was observed up in his wheelchair. The resident's fingernails on the right hand remained long and jagged with dark debris underneath them. On 8/15/25 at 1:49 p.m., Resident 23 was observed lying in bed. The resident's fingernails on the right hand remained long and jagged with dark debris underneath them. On 8/18/25 at 9:12 a.m., Resident 23 was observed up in his wheelchair. The resident's fingernails on the right hand remained long and jagged with dark debris underneath them. Resident 23's record was reviewed on 8/18/25 at 9:26 a.m. Diagnoses on the resident's profile included, but were not limited to, cerebral infarction (brain tissue death due to lack of blood supply) unspecified and hemiplegia…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-19 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure they communicated effectively with the wound specialist nurse practitioner (NP) when a resident developed a new pressure ulcer and failed to ensure appropriate infection control techniques were utilized during a dressing change for 1 of 2 residents reviewed for pressure ulcers (Resident 3). Findings include:On 8/15/25 at 2:39 p.m., Licensed Practical Nurse (LPN) 10 and the Director of Nursing (DON) were observed completing Resident 3's dressing changes to the coccyx (tailbone) and right hip. LPN 10 washed her hands, donned gloves, and removed the dressings from the resident's coccyx and right hip while wearing the same gloves. LPN 10 removed her gloves and donned a new pair of gloves but did not perform hand hygiene during the glove change. LPN 10 cleansed the wound to the resident's coccyx, removed her gloves, and donned a new pair but did not perform hand hygiene during the glove change. LPN 10 applied skin prep (protective skin…

    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 before2025-08-19 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure a indwelling urinary catheter (catheter; a tube inserted into the bladder through the urethra to drain urine) was kept from touching the floor, for 1 of 2 residents reviewed for urinary catheters (Resident 73).Findings include: During a random observation, on 8/13/25 at 3:22 p.m., the resident was observed sitting in his wheelchair in the activity room. His catheter bag (bag where urine was collected) was covered with a cloth covering and was in contact with the floor. During a random observation, on 8/15/25 at 11:03 a.m., the resident was observed sitting in his wheelchair at the activity room table. The catheter bag was covered with a cloth covering and the tubing was in contact with the floor. Resident 73's record was reviewed on 8/14/25 at 11:43 a.m. The profile indicated the resident's diagnoses included, but were not limited to, infection and inflammatory reaction due to indwelling urethral catheter (germs have entered the urinary tract through the catheter, causing an infection), urinary tract…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · Dcited before2025-08-19 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure Aplisol (solution used to test for previous exposure to tuberculosis) solution was disposed of once past the use by date during 1 of 2 medication room observations. Findings include:On 8/15/25 at 2:00 p.m., the south medication room was observed with Licensed Practical Nurse (LPN) 7. An opened vial of Aplisol was in the refrigerator with an opened date of 6/30/25. At the same time LPN 7 indicated she was not sure how long Aplisol could be used after being opened. During an interview, on 8/15/25 at 3:11 p.m., the Regional Nurse Consultant indicated Aplisol could be used for 30 days after opening and then it should have been disposed of. On 8/15/25 at 3:15 p.m., the Regional Nurse Consultant provided a document titled, Aplisol, last revised in November 2013, and indicated it was the policy currently being used by the facility. The policy indicated, .Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. 3.1-25(o)

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-19 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to follow antibiotic stewardship protocol program for 1 of 24 residents reviewed for antibiotic use (Resident 26). Findings include:During an interview, on 8/13/25 at 2:39 p.m., Resident 26 indicated she had been on a prophylactic for a while due to her getting urinary tract infections in the past. Resident 26's record was reviewed on 8/18/25 at 9:50 a.m. The profile indicated the resident's diagnoses included, but were not limited to, urinary tract infection (UTI- an infection in any part of the urinary system), acute kidney failure (sudden and rapid decline in kidney function), and dysuria (painful or uncomfortable urination). A significant change Minimum Data Set (MDS) assessment, dated 7/9/25, indicated Resident 26 was cognitively intact and had received an antibiotic medication. A physician order, dated 4/1/25 with no stop date, indicated to administer Macrobid (antibiotic) 100mg (milligram) one capsule by mouth at bedtime for UTI maintenance dose…

    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 · D2024-07-22 · 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 aid a resident in a manner that maintained or enhanced their dignity for 1 of 1 residents randomly observed for resident rights. (Resident 72). Findings include: On 7/18/24 at 10:00 a.m., observed Student Nurse Aide (4) transporting Resident 72 from the shower room to the resident's room while sitting in an open shower chair (a wheeled chair which provides support and stability to individuals who require assistance with bathing or using the restroom). The resident was wearing a blue long sleeve shirt and covered in the front with a light blanket. The back of the shower chair was uncovered, and the resident's buttocks was exposed. On 7/18/24 at 10:05 a.m., during an interview with Licensed Practical Nurse (LPN) 4 she indicated the resident should be completely covered before transporting in a shower chair. On 7/18/24 at 10:20 a.m., during an interview with Student Nurse Aide 4, she indicated the resident should have been covered prior to transporting the resident in a shower chair. On 7/18/24 at 1:30 p.m., the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-22 · tag F0622 — isolated
    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
    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 documentation of a resident's transfer included information that the physician and family representative were notified of a resident being transferred to the hospital for 1 of 2 reviewed for hospitalization (Resident 17). Finding includes: During an interview, on 7/16/24 at 11:30 a.m., Resident 17 indicated she had recently been sent out to the hospital for a seizure and stayed overnight. Resident 17's record was reviewed on 7/22/24 at 10:00 a.m. The profile indicated the resident's diagnosis included, but were not limited to, Epilepsy (group of non-communicable neurological disorders characterized by recurrent epileptic seizures [uncontrolled jerking, loss of consciousness, blank stares, or other symptoms caused by abnormal electrical activity in the brain]). A quarterly Minimum Data Set (MDS) assessment, dated 7/10/24, indicated the resident was cognitively intact. Review of the Situation, Background, Assessment, and Recommendation (SBAR) form, dated 6/18/24, indicated Resident 17 was being transported to the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-22 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure a resident's indwelling urinary catheter (catheter-a tube which is inserted into the bladder to drain urine) bag and tubing were kept from making contact with the floor for 1 of 1 residents reviewed for urinary catheters (Resident 36). Findings include: During the initial observation, on 7/16/24 at 2:03 p.m., Resident 36 was in his room sitting in a recliner. His catheter was attached to the lower portion of the recliner. The catheter urinary drainage bag (a bag attached to a indwelling urinary catheter to catch the urine) was in contact with the floor. During a random observation, on 7/17/24 at 1:16 p.m., the resident was in his room sitting in his wheelchair. The catheter tubing was observed in contact with the floor. During a random observation, on 7/18/24 at 2:13 p.m., the resident was sitting in his room in the recliner. His catheter was attached to the lower portion of his wheelchair next to the recliner. The catheter bag was observed in contact with the floor. During a random observation 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-22 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interview, the facility failed to ensure medication were labeled and stored properly for 2 of 2 medication carts and 1 of 2 medication treatment carts reviewed for medication storage (Residents 72, 63 and 5). Findings include: On 7/18/24 at 11:00 a.m., during a medication cart observation. Lantus insulin pen (an injection device that you can use to deliver preloaded insulin into your subcutaneous tissue, the innermost layer of skin in your body) with the name of Resident 72 written on the side of the pen was observed. A pharmacy prescription label was not on the pen and there was no indication of when the insulin pen had been opened. Resident 72's Lantus insulin vial (a small glass bottle, used to store medication in the form of liquids) prescription label did not indicate the date it was opened. Resident 63's Lantus insulin pen pharmacy prescription label indicated the dispense date was 5/30/24. The label did not indicate the date it was opened. Resident 5's Novolog insulin pen prescription label indicated the dispense date was 5/1/24. The prescription…

    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 · D2024-07-22 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure medications administered to a resident had been documented for 1 of 5 residents reviewed for unnecessary medication (Resident 39). Findings include: Resident 39's record was reviewed on 7/17/24 at 2:32 p.m. The profile indicated the resident's diagnoses included, but were not limited to, overactive bladder (causes sudden urges to urinate that may be hard to control), vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain), anxiety disorder (feelings of fear, dread, and uneasiness that may occur as a reaction to stress), and hyperlipidemia (elevated fats in the blood). A physician's order, dated 11/1/23, indicated to administer 1 tablet of oxybutynin chloride (used to treat symptoms of overactive bladder) 5 milligrams (mg) twice daily. The July 2024 Medication Administration Record (MAR) lacked documentation of the medication being administered on the evening shift of 7/3/24. A physician's order, dated 12/28/23,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-06 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility failed to ensure residents' self-releasing seat belts (used to keep a resident positioned properly in their wheelchair) were secured in a manner which allowed the residents to freely release the belts for 2 of 4 residents reviewed for physical restraint (Residents B and C). The deficient practice was corrected on 10/24/23, prior to the start of the survey, and was therefore past noncompliance. Finding includes: An Indiana Department of Health (IDOH) reportable incident document, dated 10/24/23 at 11:15 a.m., indicated it had been reported that Certified Nursing Aide (CNA) 8 had used tape to secure the self-releasing seat belts of Resident B and Resident C, which removed the ability of the residents to self-release the seat belts. The facility's internal investigation was initiated. The CNA was immediately re-educated by the Assistant Director of Nursing (ADON) and was suspended from work, pending the results of the investigation. During an initial observation of the Expressions (memory care) unit, on 11/6/23 at 10:05…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · D2023-06-15 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to ensure the Code Status/Advanced Directive document matched the physician's order for code status for 1 of 24 residents reviewed for advanced directives (Resident 1). Finding includes: Resident 1's record was reviewed on [DATE] at 9:00 a.m. The physician's order, dated [DATE], indicated the resident was a full code (preferred to have CPR [cardio-pulmonary resuscitation] performed, if needed as a life-saving measure). The Indiana Physician Orders for Scope of Treatment (Post), document, signed [DATE], indicated the resident preferred to be a no code (did not prefer to have CPR performed as a life-saving measure). A document posted on the door of the chart rack at the nurse's station, indicated the resident was a full code. A care plan, dated [DATE], and reviewed on [DATE], indicated the resident's code status had been designated as a no code. During an interview, on [DATE] at 9:26 a.m., Licensed Practical Nurse (LPN) 10 indicated there was a listing of…

    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 · D2023-06-15 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, observation, and record review, the facility failed to ensure the temperature and palatability of food served for 1 of 1 test tray reviewed for temperature and palatability and 2 of 26 residents reviewed for food palatability (Residents 30 and 14). Findings include: During an interview, on 6/12/23 at 9:40 a.m., Resident 30 indicated she ate meals in her room and the food was often cold when she got it. The food cart sat on the hallway. It was not passed out in a timely manner from the staff and the food got cold before she received her food tray. During an interview, on 6/12/23 at 11:52 a.m., Resident 14 indicated she ate meals in her room and the food was cold when she got the food tray. During an interview, on 6/15/23 at 11:23 a.m., the Dietary Manager (DM) indicated food temperatures should be taken when food came out of the oven, after being placed onto the steam table, and prior to being plated. The hall food trays would be placed into the hall carts with the food plate covered with a plastic lid and plastic base. During a kitchen observation, on 6/15/23 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-15 · 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 the cleanliness and sanitation of the kitchen and food preparation and storage areas for 2 of 2 kitchen observations with the potential to effect 67 of 68 residents who received food prepared in the kitchen, and the facility failed to ensure sanitary food handling when assisting residents with eating in the assisted dining room for 1 of 2 dining observations (Residents 6 and 54). Findings include: 1. On 6/11/23 at 10:52 a.m., during an initial tour of the kitchen with the Dietary Manager (DM), the following was observed: a. The flooring throughout the kitchen, dry storage room, walk-in refrigerator and walk-in freezer were observed soiled, and littered with small, dried food particles, fresh food items, small pieces of paper debris: including condiment packets and paper towel pieces. The flooring had heavy soilage buildup with a black residue at the cove bases, around the floor drains, under the wheeled storage cabinets, under the food preparation area, under the storage shelving units, and underneath,…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-15 · tag F0839 — isolated
    Employ staff that are licensed, certified, or registered in accordance with state laws.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to ensure that all licensed employees had an active Indiana license for 1 of 69 licensed employees. Finding includes: During review of employee records, on [DATE] at 11:15 a.m., a Licensed Practical Nurse (LPN) 15 was noted to have an expired Indiana nursing license. The nurse's license had been expired since 10//31/22. The nurse was noted to be an employee at the facility since 2014. Review of the nursing schedule, on [DATE] at 11:20 a.m., LPN 15 had been working during the week of the annual survey and at least the month prior. During an interview, on [DATE] at 11:28 a.m., Regional Nurse Consultant indicated that they were made aware of the expired license on [DATE] and the nurse was immediately taken off the schedule. She indicated LPN 15 had paid to renew her license on [DATE], but the state of Indiana had not renewed her license. The nurse owed money in back taxes. The nurse consultant indicated the facility nor the nurse had not realized 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.

    Administration 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 / managerTypeRoleShareSince
WITHAM MEMORIAL HOSPITALOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 11/01/2011
BAYSTON, BRETTIndividualCORPORATE DIRECTORsince 01/01/2023
BRAND, JOHNIndividualCORPORATE DIRECTORsince 01/01/2015
CASTETTER, ANDREAIndividualCORPORATE DIRECTORsince 01/01/2023
HAWKINS, CLAUDEIndividualCORPORATE DIRECTORsince 09/01/2013
HORNBECKER, MICHAELIndividualCORPORATE DIRECTORsince 01/01/2024
REAGAN, JULIEIndividualCORPORATE DIRECTORsince 09/25/2024
BRAVERMAN, KELLYIndividualCORPORATE OFFICERsince 12/01/2021
SELLERS, DANIELIndividualCORPORATE OFFICERsince 06/20/2024
MAGNOLIA HEALTH MANAGEMENT XXVII, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 11/01/2011
GUM, MELISSAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/29/2025
PARACHA, IBRARIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/29/2025
REED, STUARTIndividualOPERATIONAL/MANAGERIAL CONTROLsince 11/01/2011
REED, MICHAELIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 11/14/2025
MAGNOLIA HEALTH SYSTEMS 61, LLCOrganizationADP OF THE SNFsince 11/14/2025
MAGNOLIA HEALTH SYSTEMS INCOrganizationADP OF THE SNFsince 11/01/2011
SABRA HEALTH CARE LIMITED PARTNERSHIPOrganizationADP OF THE SNFsince 11/01/2011
WARD, JONATHANIndividualADP OF THE SNFsince 11/01/2011

CMS files one row per role, so the 20 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted.

5 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.

$8.1M
Net patient revenuemost recent cost report
-5.2%
Operating marginrevenue minus expenses
$1.9M
Related-party expense22% of expenses
Who pays — share of resident-days
Medicaid 68%Medicare 10%Other / private 22%

This home reported $1.9M paid to related parties — landlords or management companies under common ownership — equal to about 22% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$331per resident / day
operating cost
$10,062per month
≈ monthly operating cost
$315per 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 155124. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-19, 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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