Harrison Healthcare Center
150 Beechmont Dr, Corydon, IN 47112 · Non profit - Corporation · 92 certified beds · (812) 738-0550 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 1 actual-harm citation
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 3.3% | 11.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.1% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.4% | 1.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 4.8% | 25.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.1% | 3.9% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 7.4% | 11.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 29.7% | 23.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.5% | 3.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 26.3% | 23.3% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.0% | 13.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 65.3% | 79.0% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 33.5% | 22.2% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 10.8% | 10.8% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.14 | 1.61 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.21 | 1.44 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
53.2% 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 99 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 81.0% 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 42 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 0.37 therapist hours per resident per day in 2026Q1 — more than 62% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 53.2%CMS range 45.2–62.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 14.7%CMS range 11.4–20.7 | 10.7% | Oct 2022–Sep 2024 | worse than U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 81.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 69.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 76.2% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.6% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 96.9% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.4% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.0%CMS range 4.4–12.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.08 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 92 beds and averages 74.8 residents a day — about 81% occupied, or roughly 17 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 3.34 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.37 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.08 hrs/resident/day on weekends vs 3.45 on weekdays — 11% thinner on weekends. RN hours go from 0.42 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 41% 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
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.
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.
31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.
- Actual harm · Gcited before2023-09-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure the safety of a resident during an assisted transfer, which resulted in the resident falling backwards and developing a subdural hematoma and laceration to the back of her head for 1 of 3 resident reviewed for falls. (Resident E) Findings include: The record for Resident E was reviewed on 9/19/23 at 12:15 p.m. The diagnoses included, but were not limited to, cervical disc disorder with myelopathy of the cervicothoracic region, cognitive communication deficit, need for assistance with personal care, muscle weakness, and obesity. The care plan, dated 11/4/22 and last revised on 8/23/23, indicated the resident was at risk for falls, gait and balance problems, medications, weakness with an actual fall on 8/23/23. The interventions, dated 8/23/23, included, but were not limited to, apply anti-tippers to the wheelchair and send the resident to the ER (emergency room) as needed per MD (medical doctor) order. The nurse's note, dated 8/23/23 at 1:29 p.m., indicated the resident was getting ready to be put back into her bed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-29 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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 ensure a resident with a history of Urinary Tract Infections (UTIs) was provided proper management of the urinary catheter drainage system by maintaining the drainage system off the floor for 2 of 5 residents reviewed for bowel and bladder. (Residents 71 and 86)Findings include:1. During an observation, on 1/22/26 at 9:30 a.m., Resident 71's urinary catheter bag was resting on the floor next to the resident's left side of the recliner. During an observation and interview, on 1/22/26 at 12:17 p.m. Resident 71's urinary catheter bag was on the floor next to the resident's right side of the recliner. The Director of Nursing (DON) was present in the room and indicated the resident moved the catheter bag on his own. The record for Resident 71 was reviewed on 1/26/26 at 8:15 a.m. The diagnoses included, but were not limited to, retention of the urine, benign prostatic hyperplasia (BPH) (enlargement of the prostate gland), with lower urinary tract symptoms, obstructive and reflux uropathy (blockage of the urinary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-29 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 ensure a staff member followed the policy and procedure when administering narcotics for 1 of 4 residents reviewed for pharmaceutical services. (Resident B). Findings include:The clinical record for Resident B was reviewed on 1/28/26 at 11:00 a.m. The resident's diagnoses included, but were not limited to, rheumatoid arthritis with rheumatoid factor (an autoantibody found in patients with rheumatoid arthritis often signaling a more sever, aggressive, and erosive form of the disease), spinal stenosis (narrowing of the spinal canal causing increased pressure on the spinal cord and nerves), and primary osteoarthritis (degenerative joint disease characterized by the progressive breakdown of articular cartilage).A facility document, titled Individual Resident's Controlled Substance Administration Record, dated 10/10/25, indicated the form was for Resident E (a family member) of Resident B. The Morphine Sulfate (Concentrate) Oral Solution 100 milligrams (mg)/5 milliliter (ml) was signed out on the narcotic sheet on the following…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-06 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to follow medication administration parameters for a resident's (Resident M) blood pressure for 1 of 3 residents reviewed for quality of care. Findings include:The clinical record for Resident M was reviewed on 8/6/25 at 12:02 p.m. The resident's diagnosis included, but was not limited to, hypertension.The physician's order, dated 6/17/25, indicated the resident was to receive metoprolol (medication for high blood pressure) 25 mg (milligrams) two times a day in the morning and in the evening. The medication was to be held if the resident's systolic blood pressure (SBP) was less than 120.Review of the June 2025 and July 2025 medication administration record indicated the medication was administered on the following dates and times:-On 6/24/25 in the evening, the metoprolol was administered when the resident's SBP was 94-On 6/25/25 in the evening, the metoprolol was administered when the resident's SBP was 115-On 7/01/25 in the evening, the metoprolol was administered when the resident's SBP was 112-On 7/06/25 in the morning,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-06 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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 (Resident B) was provided catheter care every shift for 1 of 4 residents reviewed for Indwelling catheters.Findings include:The clinical record for Resident B was reviewed on 8/5/25 at 10:01 a.m. The resident's diagnoses included, but were not limited to, acute kidney failure and obstructive and reflux uropathy.The care plan, dated 6/20/25, indicated the resident had an Indwelling catheter and staff were to provide catheter care every shift.Review of the June 2025 Interventions and Tasks lacked documentation of Indwelling catheter care for Resident B from 6/11/25 through 6/13/25 during night shift.During an interview, on 8/6/25 at 2:43 p.m., Licensed Practical Nurse (LPN) 6 indicated catheter care should be provided every shift.On 8/6/28 at 1:28 p.m., the Director of Nursing provided a current, undated copy of the document titled Catheter Care. It included, but was not limited to, Policy.It is the policy of this facility to provide resident care that meets the.needs.of the residents.Catheter care is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure respiratory assessments were completed for a resident and failed to ensure respiratory equipment was changed weekly for 1 of 3 residents reviewed for respiratory care. (Resident D)Findings Include: On 8/5/25 at 11:40 a.m., a nebulizer machine was observed at Resident D's bedside. The handheld mouthpiece was not bagged or dated.The clinical record for Resident D was reviewed on 8/5/25 at 11:16 a.m. The resident's diagnoses included, but were not limited to, anxiety and cough.The physician's order, dated 6/2/25, indicated the resident was to receive Duoneb Solution 0.5-2.5 (3) mg (milligram)/3 ml (milliliters) via nebulizer twice daily at 8:00 a.m. and 8:00 p.m. Review of the June, July, and August 2025 medication administration records, the resident had received the breathing treatments twice daily at the ordered times.The clinical record lacked documentation of a respiratory assessment before and after the breathing treatments and weekly replacement of the nebulizer tubing, chamber and mouthpiece.During…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-06 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a resident's (Resident E) medication administration record accurately reflected the administration of narcotic pain medication for 1 of 4 residents reviewed for medication administration.Findings Include:The clinical record for Resident E was reviewed on 8/5/25 at 1:58 p.m. The resident's diagnoses included, but was not limited to, right upper arm pain and low back pain.The July 2025 medication administration record indicated the resident was to receive Oxycodone (narcotic pain medication) IR (immediate release) 5 mg (milligrams) every 6 hours as needed for pain management.The July 2025 controlled drug record indicated the resident received the medication on the following dates and times:-7/04/25 at 6:00 p.m.-7/05/25 at 12:00 a.m., 6:00 a.m. and 6:00 p.m.-7/06/25 at 12:00 a.m., 11:30 a.m. and 6:00 p.m.-7/07/25 at 12:00 a.m. and 6:00 a.m.-7/08/25 at 12:00 a.m., 8:15 a.m., 2:15 p.m. and 8:15 p.m.-7/09/25 at 2:15 a.m. and 10:00 p.m.-7/10/25 at 4:00 a.m., 10:00 a.m. and 11:30 p.m.-7/11/25 at 11:30 p.m.-7/12/25 at 5:00…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-12-18 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure oxygen concentrator filters were placed and maintained for 5 of 11 residents reviewed for respiratory care. (Residents 9, 14, 32, 45, 61) Findings include: 1. During an observation on 12/12/24 at 9:57 a.m., Resident 9's oxygen concentrator filter was 100% heavily covered with a white powdery substance. The oxygen tank's concentrator filter was pushed against the outer wall of the room. During an observation on 12/13/24 at 12:34 p.m. with the Director of Nursing (DON), the resident's oxygen concentrator filter was 100% (percent) heavily covered with a white powdery substance. The oxygen tank's concentrator filter was pushed against the outer wall of the room. The record for Resident 9 was reviewed on 12/17/24 at 8:14 a.m. The resident's diagnoses included, but were not limited to, emphysema, chronic obstructive pulmonary disease (COPD), malignant cancer of the bronchus or lung, and anxiety disorder. The physician's order, dated 1/19/22, indicated staff were to administer oxygen at 2.5 liters via nasal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-18 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to respect the dignity of residents related to ensuring the urine side of the indwelling catheter bag was not in sight of those who passed by a resident's room and to ensure a staff member spoke to a resident in a dignified manner for 2 of 20 residents reviewed for Resident Rights. (Residents 283 and 34) Findings include: 1. During an observation on 12/12/24 at 10:00 a.m., Resident 283's indwelling catheter bag was not in a dignity bag and hanging off the right side of the resident's bed. The bag showed clear urine in the bag visible from the hallway. During an observation on 12/12/24 at 12:43 p.m., the resident's indwelling catheter bag was not in a dignity bag and hanging off the right side of the resident's bed. The bag showed clear urine in the bag visible from the hallway.the catheter bag was hanging off the right side of the bed which showed the clear urine side of the bag. There was urine in the bag. During an observation on 12/12/24 2:15 p.m., the resident's indwelling catheter bag was not in a dignity…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-18 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure an appointment was scheduled for the placement of a port for 1 of 1 resident's reviewed for intravenous therapy. (Resident 63) Findings include: The record for Resident 63 was reviewed on 12/17/24 at 9:12 a.m. The resident's diagnoses included, but were not limited to, immobility syndrome (paraplegic), chronic inflammatory demyelinating polyneuritis, and bed confinement. The admission MDS (Minimum Data Set) assessment, dated 9/27/24, indicated the resident was cognitively intact. The physician's order, dated 10/30/24, indicated a referral to the surgeon for port (venous) placement for intravenous (IV) access. The resident received IgG (Immunoglobulin) infusions long term care related to poor venous access. The care plan, dated 10/30/24, indicated Resident 63 was currently on intravenous therapy for infusion therapy related to chronic inflammatory demyelination. The interventions included, but were not limited to, administer IV medications and flushes per medical provider's orders. Observe for side effects and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-18 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to follow a physician's order related to hold parameters for insulin for 1 of 6 residents reviewed for Insulin. (Resident 39) Findings include: The clinical record for Resident 39 was reviewed on 12/13/24 at 1:30 p.m A Quarterly MDS (Minimum Data Set) assessment, dated 12/6/2024, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes, hypertension, congestive heart failure, and cognitive communication deficit. The resident received insulin for 7 of 7 days during the review period. The current physician's order, with a start date of 8/14/24, indicated the resident was to receive Insulin Aspart Injection Solution 30 units subcutaneously three times a day. The staff were to hold (not administer) the insulin if the resident's blood sugar was less than 150. The October, November, and December 2024 Electronic Administration Record/Electronic Treatment Administration Record (EMAR/ETAR) indicated the Resident received the insulin when their blood sugar was less than 150 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.
Show the remaining 20 citations
- Potential for harm · D2024-12-18 · tag F0770 — failed to provide lab services — isolatedProvide 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 follow physician's order with obtaining laboratory services for 2 of 5 residents reviewed for laboratory services. (Residents 25 and 14) Findings include: 1. The clinical record for Resident 25 was reviewed on 12/16/24 at 11:32 a.m. A Quarterly Minimum Data Set (MDS) assessment, dated 12/4/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, seizures, hypertension, anxiety, depression, and bipolar. A current physician's order, with a start date of 7/1/24, indicated the staff were to obtain a Complete Blood Count (CBC), Complete Metabolic Panel (CMP), Oxcarbazepine level, Keppra level, A1C (average blood sugar over three months, thyroid stimulating hormone (TSH), Vitamin D level, and Vitamin B-12 level every three months, starting on 7/1/24. The resident's record lacked documentation of a CMP, A1C, TSH, Vitamin D, and Vitamin B-12 in July 2024. The resident's record lacked documentation of a CBC, CMP, Oxcarbazepine level, Keppra level, A1C, TSH, Vitamin…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-18 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 clean air conditioning filters and ensure resident rooms provided a homelike environment for 6 out of 7 rooms observed for environment. (Rooms 107, 109, 111, 215, 306, 309, and 311) Findings include: 1. During an observation on 10/17/24, at 10:48 a.m., in room [ROOM NUMBER], the wallpaper to the left of the air conditioning was observed to be buckled and peeled back from the wall. During an observation on 10/17/24 at 10:58 a.m., in room [ROOM NUMBER], the wall across and at bottom of the second bed was observed with a area that had been cut out and replaced. The area measured 18 inches in length and 3 ft in width. There area directly above and to the left side of where the new wall was placed, was discolored and observed to be pea green/gray in color. On 10/17/24 at 11:15 a.m., the Maintenance Director indicated the wall had mold on it from a water leak from the air conditioner which had only leaked a couple of days. He cut the molded area out last…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-06-10 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure monitoring was in place for a resident (Resident B) with a chole drain and to ensure the nursing staff followed medication parameters (Resident B, C, D and E) for 4 of 5 residents reviewed for quality of care. Findings include: 1.a. The clinical record for Resident B was reviewed on 6/8/24 at 12:13 p.m. The resident's diagnoses included, but were not limited to, cholecystitis and hypertension. The hospital Discharge summary, dated [DATE] at 10:36 a.m., indicated the resident had acute cholecystitis with sepsis and discharged with a percutaneous chole tube (drain). The admission assessment, dated 5/17/24 at 2:07 p.m., indicated the resident was admitted with a chole drain to the right side. The progress note, dated 5/17/24 at 1:51 p.m., indicated the resident had a chole drain to the right side of the abdomen with no signs or symptoms of infection observed. The nurse practitioner note, dated 5/20/24 at 12:50 p.m., indicated the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-06-10 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 maintain a sanitary environment for 2 of 3 Hallways observed. (200 Hall and 300 Hall) Findings include: 1. Upon facility entrance on 6/8/24, between 10:16 a.m. and 10:55 a.m., the following was observed on the 300 Hallway: At 10:27 a.m., in room [ROOM NUMBER], there were 2 towels and a bath blanket on the floor under the heating and air unit in room [ROOM NUMBER]. The bedside commode, across from the 2nd bed, had a dried, speckled brown substance stuck on the commode seat. The substance had a strong odor of stool. The bathroom had an out of order sign posted on it. At 10:36 a.m., room [ROOM NUMBER] had 2 towels on the floor, to the left of the bathroom door. An out of order sign was posted on the bathroom door. There was a strong urine odor in the bathroom and the floor had a puddle of water next to the toilet. A brown substance was observed on the toilet seat and on the floor, to the left of the toilet. The piping from the back 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.
- Potential for harm · Dcited before2024-06-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure respiratory equipment was bagged, when not in use, for 3 of 3 residents reviewed for respiratory care. (Residents C, D and E) Findings include: 1. The clinical record for Resident C was reviewed on 6/8/24 at 1:11 p.m. The resident's diagnosis included, but was not limited to, tracheostomy status. During an observation on 6/8/24 at 10:27 a.m., the resident was observed resting in bed with her eyes open and a tracheostomy in place. There was a suction matching on the resident's night stand with a yankauer (oral suctioning tool) and tubing connected to it. The yankauer was lying directly on the night stand and not in a bag. The physician's order, dated 6/6/24, indicated staff were to suction the resident's tracheotomy every shift and as needed. On 6/10/24 at 10:49 a.m., LPN (Licensed Practical Nurse) 6 indicated respiratory equipment and suctioning yankauers, should be bagged when not in use due to germs and infection control. 2. The clinical record for Resident D was reviewed on 6/8/24 at 1:44 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.
- Potential for harm · E2023-11-08 · tag F0727 — failed to provide required RN coverage — patternHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to schedule 8-hour consecutive RN coverage for 8 of 8 months reviewed. (April, May, June, July, August, September, October, and November 2023). This had the potential to affect all 73 residents currently residing in the facility. Findings include: The review of the April to November 2023 Licensed Nursing schedule indicated the following days were short of 8 hours consecutive RN coverage: April: Sunday 4/2 = No RN coverage scheduled Sunday 4/9 = No RN coverage scheduled Sunday 4/23 = No RN coverage scheduled Saturday 4/29 = only 6.5-hours RN coverage scheduled Sunday 4/30 = only 6.5-hours RN coverage scheduled May: Sunday 5/7 = No RN coverage scheduled Sunday 5/14 = No RN coverage scheduled Saturday 5/20 = No RN coverage scheduled Sunday 5/21 = No RN coverage scheduled Sunday 5/28 = No RN coverage scheduled June: Sunday 6/4 = No RN coverage scheduled Sunday 6/11 = No RN coverage scheduled Sunday 6/25 = No RN coverage scheduled July: Saturday 7/1 = only 6.5-hours RN coverage scheduled Sunday 7/2 = No RN coverage scheduled…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-08 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to ensure appropriate oversight of medication administration during 2 of 3 random observations. (Residents 6 and 38) Findings include: 1. During an observation on 11/5/23 at 12:24 p.m., there was a medication cup sitting on Resident 6's bedside table. The cup contained the following: a white round tablet, which was imprinted with gc 422; a yellow round tablet, imprinted with an e; a small pink round tablet, imprinted with PH 034; a small orange round tablet, imprinted with 5729; a small white round tablet, imprinted with c73; and a blue capsule, imprinted with t026 120. The resident indicated she had no idea how long the medications had been there. No staff were present in the resdient's room. During an interview on 11/1/23 at 8:50 a.m., LPN (Licensed Practical Nurse) 6 indicated she took the medications in about 20 minutes prior the resident's breakfast tray arriving. She was not supposed to leave the medications and never would again. The resident usually took her pills herself, one at a time, in applesauce and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-08 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to include the resident in the care plan meetings when developing her plan of care (Resident 51), and to revise a resident's plan of care when the discharge plan changed (Resident 59) for 2 of 34 residents care plans reviewed. Findings include: 1. During an interview with Resident 51 on 11/2/23 at 10:23 a.m., she indicated she had been in the facility for two years and thought her last care plan meeting was maybe a year ago. This was about the time the Social Worker started and she hadn't had one since. The day she was finally able to get out of bed and up into her power chair after recuperating from surgery, the Social Worker came and told her there was going to be a care plan meeting. The meeting only dealt with her weight and never discussed any other issues, such as her desire to discharge from the facility. Her family had not been involved in the meeting either and she could not remember having any other meetings after this one. She did not feel like…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-08 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure appropriate documentation of assessments and monitoring for a change in condition for (Resident 47), and to follow up in obtaining IV (intravenous) infusions as ordered and documentation of assessments for (Resident 226) for 2 of 5 residents reviewed for Quality of Care. Findings include: 1. The record for Resident 47 was reviewed on [DATE] at 10:16 a.m. The diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, type II diabetes, COPD (chronic obstructive pulmonary disease), dysphagia, pneumonia, vascular dementia, atherosclerotic heart disease, and anemia. The Quarterly MDS (Minimum Data Set) assessment, dated [DATE], indicated the resident was severely cognitively impaired. The nurse's note, dated [DATE] at 9:39 a.m., indicated therapy was assisting the resident to get in her chair with a Hoyer lift. The resident became unresponsive. Her vitals were 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.
- Potential for harm · Dcited before2023-11-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure interventions for fall prevention were implemented after a resident experienced a fall for 1 of 3 residents reviewed for accidents. (Resident 35) Findings include: 1. The record for Resident 35 was reviewed on 11/3/23 at 11:00 a.m. The diagnoses included, but were not limited to, pain in the left hip, difficulty walking, need for assistance with personal care, restless leg syndrome, and chronic pain syndrome. The nurse's note, dated 10/27/23, indicated the resident's roommate had called for the nurse at 3:34 a.m. stating the resident had fallen. The resident had a large amount of blood from her head. She wanted to go to the hospital. The IDT (Interdisciplinary Team) follow-up note, dated 10/27/23 at 9:57 a.m., indicated the resident had fallen walking to the toilet. The root cause of the incident was failure to use her bedside commode. The intervention put into place was sending the resident to the emergency department. The care plan was not updated. The care plan lacked documentation of any new preventative…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-08 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the resident's urinary symptoms were assessed while awaiting the results of a urinalysis for 1 of 3 residents reviewed for urinary tract infections (Resident C). Findings include: The record for Resident 20 was reviewed on 11/2/23 at 1:00 p.m. The diagnoses included, but were not limited to, dementia and unspecified urinary incontinence. The care plan, initiated on 10/6/20 and last revised on 7/8/21, indicated the resident had a potential for complications with bowel and bladder incontinence. The interventions included, but were not limited to, monitor labs as ordered, report results to the physician, and staff were to report changes in the urinary status to the physician. The nurse's note, dated 10/9/23 at 11:49 a.m., indicated the resident was refusing to turn and reposition. The nurse's note, dated 10/10/23 at 12:16 p.m., indicated the resident continued to refuse to turn and reposition. The Social Services note, dated 10/10/23 at 3:27 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.
- Potential for harm · D2023-11-08 · tag F0691 — failed to provide colostomy / ostomy care — isolatedProvide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure appropriate colostomy care and interventions to prevent skin breakdown surrounding a colostomy stoma were implemented for 1 of 3 residents reviewed for colostomy care. (Resident 35) Findings include: The record for Resident 35 was reviewed on 11/3/23 at 11:00 a.m. The diagnoses included, but were not limited to, colostomy status, colostomy complication, and need for assistance with personal care. The care plan, initiated on 4/22/22 and last revised on 8/17/22, indicated the resident had an alteration in bowel elimination related to a need for a colostomy and history of colon cancer. The interventions included, but were not limited to, educate the resident on ostomy care, management of ostomy site, signs and symptoms of infection, skin integrity complications and diet, encourage the resident to express feeling regarding body image due to ostomy, provide emotional support as needed, monitor bowel movements, and provide assistance with ostomy care as needed. The Skin Wound note, dated 11/9/22 at 9:18…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure appropriate orders and monitoring were in place for respiratory care for 1 of 3 resident's reviewed for respiratory care. (Resident C) Findings include: During an observation on 11/1/23 at 8:45 a.m., Resident 20 was lying abed with oxygen (O2) in place at 3 liters per minute (lpm) via nasal cannula. During an observation on 11/2/23 at 12:43 p.m., Resident 20 was lying abed with oxygen (O2) in place at 3 lpm via nasal cannula. The record for Resident 20 was reviewed on 11/2/23 at 1:00 p.m. The diagnoses included, but were not limited to, acute and chronic respiratory failure, pneumonia, and chronic obstructive pulmonary disease (COPD). The care plan, initiated on 10/6/20 and last revised on 7/8/21, indicated the resident had oxygen therapy related to COPD. The interventions included, but were not limited to, monitor for signs and symptoms of respiratory distress and report to the physician as needed, monitor pulse oximetry every shift and as needed, oxygen per physician order with humidification, and O2…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-08 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to provide medically-related social services when residents experienced the loss of independent mobility via a power chair, weight issues, the change in family dynamics, missing money and a desire to be discharged to the community despite medical obstacles for 2 of 34 residents reviewed for Social Services. (Residents 51 and 59) Findings include: 1. During an interview on 11/2/23 at 10:23 a.m., with Resident 51 she indicated she was upset because the facility took away her personal power chair due to her weight exceeding the weight limits of the chair. She indicated she was the type who got out of bed every day and was independent in mobility around the facility in her chair. The facility gave her a manual wheelchair to use, but indicated that it was uncomfortable to use and the brakes did not work when she pushed it; the wheels went the opposite way; and since her fingers did not all work, they got stuck in the spokes. The facility did give her a loaner power chair, which worked initially, but due to battery issues with it,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-08 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to ensure accurate documentation in the Controlled Drug Administration Record sheets of the administered narcotics for 3 of 45 residents receiving narcotics in 2 of 6 medication carts. (Residents 64, 59, and 60) Findings include: 1. During an observation on 11/2/23 at 12:38 p.m., of the 100 Hall Medication Cart 1 with LPN (Licensed Practical Nurse) 4, the following concern was observed: - Resident 64's lorazepam 0.5 mg (milligrams) Controlled Drug Administration Record sheet, indicated the resident had a count of 2 tablets left. The last dose signed out on the sheet was on 11/2/23 at 8:36 a.m., by LPN 4. There was 1 tablet of the medication on the card. During an interview on 11/2/23 at 12:40 p.m., LPN 4 indicated he had just given the medication. The record for Resident 64 was reviewed on 11/6/23 at 2:10 p.m. The diagnoses included, but was not limited to, anxiety disorder. The care plan, dated 8/4/23 and last revised 8/16/23, indicated the resident used anti-anxiety medication related to anxiety disorder. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-08 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure appropriate infection control practices for Enhanced Barrier Protocol (EBP) were followed for 1 of 3 residents reviewed for infection control. (Resident 16) Findings include: During an observation on 11/1/23 at 12:22 p.m., Resident 16's door had a sign on the outside that indicated she was in Enhanced Barrier Precautions and staff were to don a gown and gloves for high-contact resident activities, including dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or toileting, device care or use, and wound care for any skin opening requiring a dressing. Upon entering the room, CNA (Certified Nurse Aide) 10 was observed to be coming away from the resident's bed with a graduated cylinder nearly full of brown liquid stool. A strong odor of stool was present. CNA 10 was not wearing a gown. She proceeded to empty the stool into the toilet. CNA 11 was in the room with Resident, providing direct care for the resident's colostomy and was sealing the bag. She was not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-08 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 residents were offered pneumococcal vaccinations as recommended by the CDC (Centers for Disease Control) for 2 of 5 residents reviewed for pneumococcal immunizations. (Residents 35 and 9) Findings include: 1. The record for Resident 35 was reviewed on 11/6/23 at 8:30 a.m. The record indicated Resident 35 was [AGE] years old and had received a dose of PCV20 (pneumococcal polysaccharide vaccine) on 3/2/23, however had received no further doses. On 11/8/23 the facility provided a copy of the resident's most current vaccination status from CHIRP (Child and [NAME] Immunization Registry Program), which indicated the resident had received no doses of PCV20, and only one dose of PCV13 on 11/6/2015. The record lacked documentation of any offer for the resident to receive the recommended second dose of either PCV20 or PPSV23 (pneumococcal polysaccharide vaccine) after one year as recommended by the current CDC (Centers for Disease Control) guidance. 2.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-08 · tag F0908 — failed to keep essential equipment working — isolatedKeep all essential equipment working safely.
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 an electric wheelchair loaned to a resident by the facility was maintained in safe operating condition for 1 of 2 resident reviewed for patient equipment. (Resident 51) Findings include: During an interview with Resident 51 on 11/2/23 at 10:10 a.m., she indicated her personal electric wheelchair was removed due to her being over the weight limit of the chair. She was given a donated wheelchair from the facility to use until she lost sufficient weight, to use hers again. She indicated it was an older model and had been only able to use it for 2 days since the battery would not keep a charge once it was removed from the plug despite it initially indicating it was charging and then fully charged. The record for Resident 51 was reviewed on 11/3/23 at 12:40 p.m. The diagnoses included, but were not limited to, personal history of traumatic brain injury, unspecified intracranial injury with loss of consciousness of unspecified duration, morbid obesity, paraplegia unspecified and adjustment disorder with mixed anxiety and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-06 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure room change/new roommate forms were completed; a resident's representative was notified of a room change; and to ensure resident psychosocial follow-ups were in place for 2 of 3 residents reviewed for notification of changes. (Residents B and C) Findings include: 1. The clinical record for Resident B was reviewed on 9/5/23 at 11:28 a.m. The diagnoses included, but were not limited to, mild cognitive impairment and traumatic brain injury. Resident C was moved into Resident B's room on 8/19/21. Resident B was moved out of the room and into another room on 8/21/23. During an interview on 9/5/23 at 11:52 a.m., the SSD (Social Services Director) indicated on 8/19/23 she was out of the office due to illness when Resident B received a new roommate. The SSD note, dated 8/21/23 at 1:04 p.m., indicated the family was notified of a room change (two days after the receiving a new roommate). The clinical record lacked documentation of a new roommate form on 8/19/23, a room change form on 8/21/23, or any psychosocial adjustment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-06 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure daily Respiratory/COVID Symptoms evaluation were completed for 2 of 3 residents reviewed for infection control. (Residents E and F) Findings include: 1. The clinical record for Resident E was reviewed on 9/5/23 at 2:09 p.m. The diagnosis included, but was not limited to, COVID-19. The COVID-19 infection list, provided by the RDCO (Regional Director of Clinical Operations) on 9/5/23 indicated Resident E tested positive for COVID-19 on 8/25/23. Review of the Respiratory/COVID Symptoms Evaluation assessments lacked documentation of an assessment completed on 8/26/23, 8/27/23, 8/30/23, 8/31/23, 9/1/23, 9/3/23 and 9/4/23. During an interview on 9/6/23 at 10:45 a.m., LPN (Licensed Practical Nurse) 5 indicated respiratory/COVID evaluations should be completed daily on residents with COVID-19. 2. The clinical record for Resident F was reviewed on 9/5/23 at 2:20 p.m. The diagnosis included, but was not limited to, COVID-19. The COVID-19 infection list, provided by the RDCO (Regional Director of Clinical Operations) on 9/5/23…
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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to COMMUNICARE HEALTH — 110 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.2 | +0.8 vs chain |
| Health inspection | 3 of 5 | 2.7 | +0.3 vs chain |
| Staffing | 2 of 5 | 2.6 | -0.6 vs chain |
| Quality measures | 5 of 5 | 4.5 | +0.5 vs chain |
The other 109 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 109; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| BORNE-BAUMAN, CANDICE | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2023 |
| FLUECKIGER, RUSSELL | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2023 |
| LEHMAN, SCOTT | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2023 |
| MACKLIN, LARRY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2023 |
| MCINTIRE, DAVID | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2023 |
| SMITH, SCOTT | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2023 |
| SPRUNGER, KYLE | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2023 |
| WHEELER, DANE | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2023 |
| ADAMS COUNTY MEMORIAL HOSPITAL | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2023 |
| BEECHMONT II MGT CO LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2017 |
| MASROOR, MUHAMMAD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/01/2020 |
| ODENTHAL, RICHARD | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 09/01/2017 |
| PACE, SANDI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/11/2024 |
| BLUE MANAGEMENT SERVICES LLC | Organization | ADP OF THE SNF | since 12/01/2023 |
| FIRST BANK OF BERNE | Organization | ADP OF THE SNF | since 12/01/2023 |
| OMEGA HEALTHCARE INVESTORS INC | Organization | ADP OF THE SNF | since 09/01/2017 |
| OMG IN MSTR LSCO LLC | Organization | ADP OF THE SNF | since 12/10/2025 |
CMS files one row per role, so the 28 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $182K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Indiana Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 155657. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-29, 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.