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Willow Crossing Health & Rehabilitation Center

3550 Central Ave, Columbus, IN 47203 · Government - County · 112 certified beds · (812) 379-9669 Medicare & Medicaid certified

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Flagged for abuseBehavioral-health or dementia-care citations — no harm found (F0740, F0744)1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)
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
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2026
  • 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 (26) — 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 (2/5)
  • its facility-reported quality-measure rating is low (2/5)
  • about 29% 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.

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3581 Central Ave · (812) 372-0137 · Call to confirm hours
Pharmacy
3060 N National Rd · (812) 376-9566 · Call to confirm hours
Grocery
3060 N National Rd · (812) 376-9451 · Call to confirm hours
Park
Whitney Ct · Typically dawn to dusk
Place of worship
1780 Rocky Ford Rd · (812) 372-5889

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 2 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 1 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 rating1★
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 increased27.4%11.0%15.4%worse
Long-stay residents who lose too much weight5.6%5.5%5.4%typical
Long-stay residents with a catheter left in their bladder0.3%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.3%1.1%2.0%better
Long-stay residents with depressive symptoms84.3%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 injury5.5%3.9%3.3%worse
Long-stay residents whose ability to walk worsened21.6%11.9%16.1%worse
Long-stay residents on antianxiety or hypnotic medication37.6%23.5%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.4%95.3%typical
Long-stay residents with pressure ulcers1.2%3.6%4.7%better
Long-stay residents with worsening bladder/bowel control23.9%23.3%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table18.5%13.6%17.1%typical
Short-stay residents who newly got an antipsychotic medication1.3%1.2%1.4%typical
Short-stay residents given the seasonal flu vaccine97.7%79.0%79.4%better
Short-stay residents rehospitalized after admission21.8%22.2%22.6%typical
Short-stay residents with an outpatient ER visit18.5%10.8%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.711.611.67typical
Long-stay outpatient ER visits per 1,000 resident days1.681.441.80typical

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.

39.0% 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 50 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

39.0%U.S. median 51.5%
Got home and stayed home
11.5%U.S. median 10.7%
Went back to hospital
53.7%U.S. median 56.6%
Met the expected recovery
0.31U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 53.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 41 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 26% 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 SNF39.0%CMS range 27.0–52.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.5%CMS range 7.7–15.210.7%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 discharge53.7%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge53.7%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 discharge58.5%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.8%CMS range 4.4–11.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.851.02Oct 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

0.57
RN hours/ resident / day
0.57
LPN hours/ resident / day
2.32
Aide hours/ resident / day
3.46
Total nurse hours/ resident / day
0.34
RN hoursweekends
48.4%
Total nursing turnover
42.9%
RN turnover

How full it usually is: this home is certified for 112 beds and averages 102.3 residents a day — about 91% occupied, or roughly 10 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.46 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.32 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 2.69 hrs/resident/day on weekends vs 3.77 on weekdays — 29% thinner on weekends — a notable drop. RN hours go from 0.66 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 48% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

5
deficiencies at the latest standard inspection (2026-03-11)
6
at the previous standard inspection (2025-02-18)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

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

  • Actual harm · Gcited before2026-02-19 · 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

    Based on observation, interview, and record review, the facility failed to ensure a resident was free of physical and mental abuse by a staff member purposely and forcefully causing a resident to fall from the wheelchair onto the floor. This resulted in the staff member leaving the resident lying on the floor with no assistance, she walked away from the resident going into other resident rooms, while another resident was maneuvering their wheelchair around the resident, and the staff member failed to provide accurate details related to the fall for assessment and follow-up care for 1 of 6 residents reviewed for abuse (Resident B). Using the reasonable person concept, it is likely this would lead to fear, confusion, anxiety, and intimidation for Resident B. Findings include:The clinical record for Resident B was reviewed on 02/17/2026 at 11:22 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 12/31/2025, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, depression, anxiety, and unspecified dementia (decline…

    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 · Ecited before2026-03-11 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record and interview, the facility failed to follow physician's orders related to hold parameters and obtaining vital signs for cardiac medications for 7 of 21 residents reviewed for quality of care. (Residents 44, 62, 30, 10, 3, 8, and 104) Findings include:1.The clinical record for resident 44 was reviewed on 03/10/2026 at 10:30 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 01/01/2026, indicated the resident was cognitively intact. The resident's diagnosis included, but was not limited to, hypertension. An open-ended physician's order, with a start date of 12/22/2025, indicated the resident was to be given midodrine 10 milligrams (mg) twice a day for orthostatic hypertension. The staff were to hold, not give, the medication, if the resident's systolic blood pressure (top number) was greater than 130. The January, February, and March 2026 Electronic Medication Administration Record (EMAR) indicated the resident had received the medication on the following days and times when the resident's systolic blood pressure was greater than 130: -On 01/03/2026 from 6:30…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-11 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to maintain resident records in a private manner related to computer screens being left open with resident information visible for 3 random observations. (Residents 32 and 33)Findings include:During an observation, on 03/09/2026 at 10:18 A.M., the computer screen on the 100 Hall Medication Cart 1 was observed to have Resident 32's personal and medical information visible and was left unattended. - On 03/09/2026 at 10:18 A.M., a staff member walked by the medication cart,- On 03/09/2026 at 10:19 A.M., a resident walked by the medication cart, - On 03/09/2026 at 10:19 A.M., a Certified Nurse Aide (CNA) walked by the medication cart,- On 03/09/2026 at 10:20 A.M., RN 3 returned to the medication cart. During an observation, on 03/09/2026 at 11:58 A.M., the computer screen on the 100 Hall Medication Cart 2 was observed to have resident information visible and was left unattended. - On 03/09/2026 at 11:59 A.M., the Administrator and the Assistant Director of Nursing (ADON) walked by the medication cart,- On 03/09/2026 at 12:00 P.M.,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-11 · 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 interview, record review, and observation, the facility failed to ensure appropriate procedure was followed during providing care for a suprapubic urinary catheter replacement for 1 of 2 residents reviewed for urinary catheters. (Resident 78) Findings include:The clinical record for Resident 78 was reviewed on 03/09/2026 at 9:46 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 01/30/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, neurogenic bladder (dysfunction of the urinary bladder caused by nervous system damage), and obstructive uropathy (structural or functional blockage of urine flow anywhere along the urinary tract). The resident had an indwelling urinary catheter. The Electronic Medication Administration Record (EMAR) for February and March 2026, indicated the resident had received the antibiotic Ciprofloxacin 250 milligrams twice a day from 02/25/2026 through 03/03/2026 for a urinary tract infection. The procedure for changing the resident's indwelling suprapubic urinary catheter was observed…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-11 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to have medications available to residents for 2 of 24 residents reviewed for pharmacy services. (Residents 10 and 104)Findings include: 1.The clinical record for Resident 10 was reviewed on 03/10/2026 at 11:50 A.M. A Quarterly MDS assessment, dated 01/12/2026, indicated the resident was moderately cognitively impaired. The resident's diagnosis included, but was not limited to, non-Alzheimer's dementia (mental decline). An open-ended physician's order, with a start date of 09/09/2025, indicated the resident was to be given Aricept (a dementia medication) 10 mg at bedtime. The January, February, and March, 2026 EMAR indicated the resident did not receive the medication on the following dates due to the medication being unavailable: 01/03/2026, 01/04/2026, 01/11/2026, 01/17/2026, 01/18/2026, 01/25/2026, 01/31/2026, 02/05/2026, 02/07/2026, 02/08/2026, 02/14/2026, 02/15/2026, 02/16/2026, 02/19/2026, 02/21/2026, 02/22/2026, 02/28/2026, 03/01/2026, 03/07/2026, and 03/08/2026. 2. Resident 104's clinical record was reviewed on…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-11 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to track infections for 3 of 12 residents reviewed for antibiotic stewardship. (Residents 10, 22, and 78)Findings include:1.The clinical record for Resident 10 was reviewed on 03/10/2026 at 11:50 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 01/12/2026, indicated the resident was moderately cognitively impaired. The resident's diagnosis included, but was not limited to, urinary tract infection. A physician's order, dated 09/19/2025 through 09/24/2025, indicated the resident was to be given Avycaz (an antibiotic medication) 2.5 grams, every 8 hours for resistance to carbapenem (an antibiotic medication), for a urinary tract infection. The Electronic Medication Administration Record (EMAR) indicated the resident had received the medication. The September 2025 Infection Control Tracking Log lacked indication the resident had received an antibiotic in September 2025. A physician's order, dated 11/14/2025 through 11/21/2025, indicated the resident was to be given Cipro (an antibiotic) 250 milligrams (mg), twice a day…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-19 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    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 a resident with a major mental illness was appropriately supervised during a physical/mental outburst for 1 of 6 residents reviewed for behavior health services. (Resident B). Findings include:The clinical record for Resident B was reviewed on 02/17/2026 at 11:22 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 12/31/2025, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, depression, anxiety, unspecified dementia (mental decline), and a history of visual hallucinations. The resident utilized a wheelchair and walker for mobility. An Incident Report, dated 02/11/2026 at 11:23 P.M., indicated Resident B had grabbed a stationary chair that Resident F was sitting in, and made negative comments towards them. The staff intervened to separate the two residents. Resident B continued to go towards the staff and Resident F in an intimidating manner. A Progress Note, dated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-18 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to follow physician's orders related to medication hold parameters for 2 of 22 residents reviewed for Quality of Care. (Residents 71 and 5) Findings include: 1. The clinical record for Resident 71 was reviewed on 02/17/25 at 9:00 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 11/13/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, schizoaffective disorder, heart failure, hypertension, diabetes, and depression. The current open-ended physician's order, with a start date of 09/03/24, indicated the resident was to receive Lisinopril (a blood pressure medication) 10 milligrams (mg), twice a day. The staff were to hold the medication when the systolic blood pressure (SBP) was less than 130 or the heart rate was less than 60. The January and February 2025 Electronic Medication Administration Record (EMAR) indicated the resident had received the medication when the blood pressure was less than 130 or the heart rate was less than 60 on the following dates and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-18 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to prevent and ensure a resident's wound was identified prior to the resident developing a Stage III pressure ulcer for 1 of 3 residents reviewed for pressure ulcers. (Resident 64) Findings include: The resident's clinical record was reviewed on 02/18/25 at 1:29 P.M. A Quarterly Minimum Data Set assessment, dated 07/16/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, stroke, hemiplegia affecting the right dominate side, malnutrition, dementia, peripheral vascular disease, and neuromuscular dysfunction of the bladder. The resident was always incontinent of bowel and had an indwelling urinary catheter. The resident was dependent on staff for toileting, hygiene, and mobility, including rolling left to right. The resident was at risk for pressure ulcers but had no pressures at the time of the assessment. The resident utilized pressure reducing devices for the bed and chair. The clinical record lacked documentation the resident had been absent…

    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 · D2025-02-18 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to document meal consumption values for 2 of 4 residents reviewed for nutrition. (Residents 55 and 62) Findings include: 1. A Quarterly Minimum Data Set (MDS) assessment, dated 01/29/25, indicated Resident 55 was cognitively intact. The resident's diagnoses included, but were not limited to, hypertension, urinary tract infection, seizure disorder, anxiety, depression, and bipolar. The resident had experienced weight loss. A Weight Loss Care Plan, with a start date of 01/18/25, included, but was not limited to, the following intervention: Monitor meal consumption and encourage resident to consume 100% (percent) of meals. The January and February 2025 Meal Consumption Record for the resident lacked documented meal intake values for the following dates: - 01/18/25 at dinner, - 01/26/25 at lunch, - 02/03/25 at breakfast, - 02/10/25 at dinner, and - 02/17/25 at breakfast. 2. A Quarterly MDS assessment, dated 11/27/24, indicated Resident 62 was severely cognitively impaired. The resident's diagnoses included, but were not limited…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-18 · 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 observation and interview, the facility failed to store medications appropriately for 2 of 3 medication carts reviewed. (Back 200 Medication Cart and Front 100 Medication Cart) Findings include: 1. The Back 200 Medication Cart was observed, on 02/18/25 at 2:33 P.M, with Qualified Medication Aide (QMA) 9. The medication cart contained the following loose pills laying loose in the bottom of the drawers: - two small round white tablets, - one small oval white tablet, and - one small oval blue tablet. The medication cart had several bits of debris/paper that were scattered heavily throughout the cart. During an , on 02/18/25 at 2:35 P.M., QMA 9 indicated she didn't clean the medication cart; she just passed the medications. 2. The Front 100 Medication Cart was observed, on 02/18/25 at 2:39 P.M., with QMA 8. The medication cart contained the following loose pills laying loose in the bottom of the drawers. - one small round white tablet, - one medium round white tablet, and - one large round white tablet. The medication cart had several bits of debris/paper that were scattered…

    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
Show the remaining 15 citations
  • Potential for harm · D2025-02-18 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to obtain a urinalysis in a timely manner for 1 of 4 residents reviewed for laboratory services. (Resident 36) Findings include: A Quarterly Minimum Data Set assessment, dated 11/06/24, indicated Resident 36 was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, vascular dementia, diabetes, and stroke. A progress note, dated 01/02/25 at 1:47 P.M., indicated the resident had a new physician's order to obtain a urine dip (a rapid urine test performed in the facility). If the urine dip was positive, nursing staff were to obtain a urine sample to send to the lab for urinalysis (UA) and a Culture and Sensitivity (C&S). The resident's family member was notified. The lab report from the urinalysis indicated the urine sample was collected on 01/07/25 and resulted on 01/08/25. The report indicated there were greater than 100,000 CFU/ml (colony forming units per milliliter) of Streptococcus beta hemolytic Group B bacteria. The bacteria were universally susceptible to Penicillins (a type 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-18 · 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 and interview, the facility failed to follow infection control guidelines during dining service for 1 of 2 dining observations. (Residents 102 and 15) Findings include: During a continuous observation on 02/12/25, from 11:49 A.M. to 11:57 A.M., in the Dementia Unit Dining Room, the following was observed: At 11:49 A.M., Activity Aide (AA) 10 sat an empty lunch tray on a table, opened the trash can lid with her bare left hand, threw some trash into the can, went to the meal cart, and moved around several meal trays within the cart that were to be served to the residents. She retrieved a tray from the cart and served it to Resident 102. After serving the tray she sanitized her hands. At 11:54, she sat an empty tray on a table; opened the trash can lid with her bare left hand; threw some trash into the can; went to the meal cart; and moved several resident meal trays within the cart. She retrieved a meal tray and served it to Resident 15. After serving the tray she sanitized her hands. During an interview, on 02/18/25 at 1:31 P.M., Certified Nurse Aide (CNA) 7…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-28 · 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 interview and record review, the facility failed to ensure a resident with a urinary tract infection received antibiotic treatment in a timely manner for 1 of 3 residents reviewed for urinary tract infections. (Resident B). Findings include: The clinical record for Resident B was reviewed on 08/28/24 at 2:00 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 08/05/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, stroke, diabetes, renal insufficiency, and neurogenic bladder. The resident was incontinent of bowel and bladder. A progress note, dated 07/10/24 at 9:00 A.M., indicated the resident's family member requested the resident's urine be tested for a UTI (urinary tract infection). The NP (Nurse Practitioner) was in the facility and ordered a UA (urinalysis) with a C&S (Culture and Sensitivity, an additional test used to determine the appropriate antibiotic to use if infection was present) if indicated. A progress note, dated 07/12/24 at 4:50 P.M., indicated the results of the C&S were still…

    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 · Past Non-Compliance
  • Potential for harm · Ecited before2024-04-19 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store medications appropriately for 2 of 3 medication carts reviewed and for 6 of 15 resident medications reviewed. (Residents 41, 88, 36, 91, 23, and 13) Findings include: 1. During an observation on 04/14/24 at 9:53 A.M., the back 200 Hall medication cart had the following residents' controlled medications preset for the noon medication pass: - Resident 41's Oxycodone 7.5/325 mg (milligrams) and lorazepam 1 mg, - Resident 88's hydrocodone-acetaminophen 7.5-325 mg, - Resident 36's Lyrica 50 mg and hydrocodone-acetaminophen 7.5-325 mg, - Resident 91's tramadol 50 mg, and - Resident 23's hydrocodone-acetaminophen 10-325 mg. During an interview on 04/14/24 at 9:55 A.M., LPN (Licensed Practical Nurse) 8 indicated she usually preset resident medications for the next medication pass by placing them in a medication cup and labeling them with the resident's name. She placed the cup in the top drawer of the medication cart. 2. During an…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-19 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure food was served in a sanitary manner for 2 of 4 dining observations and 4 of 5 staff observations. (CNA 3, CNA 17, QMA 16, and CNA 5) Findings include: 1. During a dining observation in the Memory Care Unit on 04/14/24 the following occurred: - At 12:20 P.M., CNA (Certified Nurse Aide) 3 delivered Resident 70's meal. She removed the plate and cups from the tray and placed them on the table. She removed a dinner roll from the clear plastic package with her bare hand, placed the package on the table, and placed the roll on top of the package. - At 12:23 P.M., CNA 17 delivered Resident 159's meal. She removed the plate and cups from the tray and placed them on the table. She removed a dinner roll from the plastic package with her bare hand and set the package on the table. She sat the roll on top of the package. - At 12:26 P.M., CNA 3 delivered Resident 90's meal. She removed the plate and cups from the tray and placed them on the table. She removed a dinner roll from the plastic package with her bare hand and set the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-19 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to to protect resident information related to unlocked computer screens for 4 of 6 random observations for personal privacy. Findings include: During an observation on 04/14/24 at 10:02 A.M., a 200 Hall medication cart had a computer screen opened to resident names and list of medications. The opened computer screen was in the resident hallway on top of the medication cart. There was no staff with in 20 to 30 feet of the medication cart. The DON (Director of Nursing) closed the computer screen as he was walking down the hall passed the cart at 10:03 A.M. During an continuous observation on 04/14/24 at 12:15 P.M. to 12:17 P.M., the front 200 Hall medication cart had a computer tablet on top of the cart. The screen was opened to the resident names and pictures. QMA (Qualified Medication Aide) 9 was in room [ROOM NUMBER] talking with a resident, at 12:17 P.M. she came out of room [ROOM NUMBER] and picked the tablet up off of the medication cart. On 04/15/24 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-19 · 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

    Based on interview and record review, the facility failed to ensure a resident was free from mental and physical abuse for 1 of 23 residents reviewed for abuse. (Resident 203) Findings include: A facility reported incident, dated 12/30/23, indicated CNA (Certified Nurse Aide) 20 had became agitated and had spoken to Resident 203 inappropriately during care. The resident's clinical record was reviewed on 04/19/24 at 12:37 P.M. A Quarterly Minimum Data Set assessment, dated 10/18/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, hypertension, diabetes, Alzheimer's disease, stroke, anxiety, and stage 4 chronic kidney disease. During an interview on 04/19/24 at 10:46 A.M., CNA 21 indicated on 12/30/23 she was providing care to the roommate of Resident 203 when she heard CNA 20 become agitated with Resident 203. She stepped around the curtain and assisted CNA 20 with the residents care. CNA 20 told Resident 203 if you hit me again I'll hit you back, CNA 20 then took a wet wipe and smacked at the resident's face, and pushed 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2024-04-19 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to follow physician's orders related to hold parameters for a blood pressure medication for 1 of 23 residents reviewed for quality of care. (Resident 48) Findings include: The clinical record for Resident 48 was reviewed on 04/16/24 at 1:35 P.M. A Quarterly Minimum Data Set assessment, dated 01/20/24, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, dementia, heart failure, hypertension, stroke, diabetes, anxiety, and depression. A current physician's order, with a start date of 03/29/24, indicated the resident was to get losatan 100 mg (milligrams), one time a day, for hypertension. The staff were to hold the medication if the resident's systolic blood pressure (the top number) was less than 110 or the heart rate was less than 60. The clinical record that included the March and April 2024 EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) lacked indication the resident's blood pressure and heart rate had been obtained…

    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 before2024-04-19 · 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

    Based on record review and interview, the facility failed to prevent and follow physician's orders related to a pressure ulcer for 1 of 4 residents reviewed for pressure ulcers. (Resident 48) The clinical record for Resident 48 was reviewed on 04/16/24 at 1:35 P.M. A Quarterly Minimum Data Set assessment, dated 01/20/24, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, dementia, heart failure, hypertension, stroke, diabetes, anxiety, and depression. A physician's order with a start date of 03/11/24 and discontinue date of 04/18/24, indicated the resident was to wear Blue Prevalon boots at all times. An Initial Pressure Ulcer Assessment form, dated 03/14/24, indicated a suspected deep tissue injury (a purple or maroon area of discolored intact skin due to damage of underlying tissue) was discovered on the right medial heel. On 04/16/24 at 11:27 A.M., the resident was observed in bed without her blue boots on. On 04/16/24 at 2:54 P.M., the resident was observed in bed without her blue boots on. The blue boots were observed on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-19 · 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, interview, and record review, the facility failed to provide appropriate urinary catheter care for a resident with frequent Urinary Tract Infections for 1 of 5 residents reviewed for bladder incontinence care. (Resident 72) Findings include: During an observation on 04/18/24 at 9:46 A.M., CNA (Certified Nurse Aide) 4 washed her hands, closed the door to Resident 72's room with her foot, and donned gloves. The left glove ripped and as she removed the glove, it fell to the floor. She picked it up with her gloved right hand, put it in the trash, and donned a new glove to her left hand. She went to the resident's closet and donned a gown. She moved the resident's bedside table, sat towels down on top of the table, and picked up a bath basin off of the table. She went into the bathroom and turned on the water with her right gloved hand. She returned to the room and moved the bedside table, opened the top drawer of the nightstand, retrieved a container of soap, and sat it on the bedside table. CNA 4 went back to the bathroom and retrieved a graduated cylinder. She…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-19 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to implement interventions and complete behavior forms related to dementia care for 1 of 3 residents reviewed. (Resident 69) Findings include: The clinical record for Resident 69 was reviewed on 04/19/24 at 2:18 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 01/01/24 indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, anxiety, depression, and psychotic disorder. The resident had several days of feeling down and depressed, had trouble sleeping, feeling tired, and having a poor appetite. The complete Care Plan was provided by the DON on 04/18/24 at 2:50 P.M., and included, but was not limited to, a Care Plan for Wandering, with a most recent revision date of 01/12/24. The interventions included, but were not limited to, door alarm placed on res. (resident's) room door. The EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) for March and April 2024 were provided by the DON on 04/19/24…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-26 · tag F0887 — pattern
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    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 provide COVID-19 booster immunizations for 8 of 10 residents reviewed for immunizations (Resident F, G, L, M, C, D, E, and H) Findings include: 1. The clinical record for Resident F was reviewed on 10/25/23 at 10:30 A.M. An admission MDS (Minimum Data Set) assessment, dated 10/06/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, cancer, anemia, heart failure, hypertension, diabetes, anxiety, and depression. The resident's admission Packet, dated 10/03/23, indicated the resident requested the facility would ensure the resident received the COVID-19 booster as soon as it was available. The form was signed by the resident. The resident had the following COVID-19 immunizations: 01/30/21, 02/20/21, and 11/20/21. The clinical record lacked indication the resident had received a COVID-19 booster since 11/20/21 or since admission on [DATE]. The resident was COVID-19 positive on 10/19/23. 2. The clinical record…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-26 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During a continuous observation on 10/25/23 from 11:53 A.M. to 12:23 P.M., of Medication Cart 2, located in the hallway across from the nurse's station, was unlocked. At 11:53 a.m., one nursing staff member was located in the nurses station. At 11:55 a.m. to 12:23 p.m., there were no nursing staff in consistent observation of the unlocked medication cart. Several staff members including, but not limited to, the DON (Director of Nursing), a housekeeper, a maintenance man, a dietary aide, and CNA (Certified Nurse Aide) 10 had walked by the unlocked medication cart. During an interview on 10/25/23 at 12:23 P.M., The DON indicated the medication cart should have been locked if the nurse was not standing by it and medication should not be left sitting out at the nurse's station unattended. The current STORING DRUGS policy, dated 12/2017, was provided by the ADON (Assistant Director of Nursing) on 10/26/23 at 3:27 P.M. The policy indicated, .Drugs and biologicals will be stored in a safe, secure, and orderly manner…

    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 · D2023-10-26 · 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 observation and interview, the facility failed to maintain readily accessible, accurate, and systematically organized resident records for 1 of 12 resident records reviewed. (Resident H) Findings include: The Nurse's Notes for Resident H from readmission in September 2022 to present were requested from the facility on 10/26/23 at 1:22 P.M. During an observation and interview on 10/26/23 at 4:30 P.M., several staff members, including but not limited to, the Clinical Support Nurse, the DON (Director of Nursing), and the Administrator, were in the Medical Records office sorting through stacks of loose papers. The room had multiple stacks of papers on tops of cabinets, the desk, and tables. The staff were sorting through papers in search of the resident's Nurse's Notes. The Clinical Support Nurse indicated the facility did not currently have a Medical Records staff person and residents' records had piled up and were not separated by each resident. One page of hand written Nurse's Notes for Resident H was provided by the Administrator on 10/26/23 at 4:33 P.M. There were notes on…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-06 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide appropriate wound care related to infection control procedures for 2 of 3 residents reviewed for pressure ulcers. (Resident B and C) Findings include: 1. The clinical record for Resident C was reviewed on 10/5/23 at 11:24 a.m. A Quarterly MDS (Minimum Data Set) assessment, dated 8/31/23, indicated the resident only required supervision for mobility and transfers, and was always continent of bladder and bowel. No skin issues were noted. Her diagnoses included, but were not limited to, cellulitis of the left great toe, osteomyelitis, surgical amputation of the left great toe, and diabetes myelitis type 2 with hyperglycemia and chronic kidney disease. A Physician's Order, dated 9/20/23, indicated the wound location was the left great toe and it was a surgical wound. Nursing staff were to cleanse the open area with normal saline (may use wound cleanser if normal saline was contraindicated) dry, paint the toe with betadine, cover with a Telfa (a non-adherent dressing), wrap with kerlix (rolled gauze) and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“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 XI LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 11/01/2011
MILLER, ALISHAIndividualOPERATIONAL/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 65 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.

$14.6M
Net patient revenuemost recent cost report
+19.3%
Operating marginrevenue minus expenses
$3.5M
Related-party expense29% of expenses
Who pays — share of resident-days
Medicaid 78%Medicare 6%Other / private 16%

About 78% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $3.5M paid to related parties — landlords or management companies under common ownership — equal to about 29% 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

$329per resident / day
operating cost
$9,989per month
≈ monthly operating cost
$407per 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 155535. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-11, 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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