Waters Of Covington, The

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

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.

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.

47.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 59 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 22.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 31 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 0.15 therapist hours per resident per day in 2026Q1 — more than 12% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% 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.

Staffing

How full it usually is: this home is certified for 119 beds and averages 77.1 residents a day — about 65% occupied, or roughly 42 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.40 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.43 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.48 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.18 hrs/resident/day on weekends vs 3.49 on weekdays — 9% thinner on weekends. RN hours go from 0.48 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 49% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

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

Inspection deficiencies

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

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.

38 citations, most serious first. The 14 most serious are shown; the remaining 24 are one tap away and print in full.

• Immediate jeopardy · J2025-10-20 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident's right to be free from neglect when staff ignored a resident's continued reports of acute pain and his request to be sent to the hospital which resulted in prolonged pain and a delay of treatment for 1 of 3 residents reviewed for neglect (Resident B). The immediate jeopardy began on 9/24/25 at 10:00 p.m., when Certified Nursing Aide (CNA) 3 observed Resident B to be sweaty and he complained of acute pain. CNA 3 reported his concerns to Licensed Practical Nurse (LPN) 4. CNA 3 and CNA 8 reported to LPN 4 around 1 or 2 a.m., that Resident B was still in pain and wanted to see the nurse. LPN 4 failed to assess the resident or report the resident's change of condition to a physician. CNA 3 reported Resident B's pain to the incoming dayshift nurse, Registered Nurse (RN) 5. On 9/25/25 around 7:40 a.m., CNA 6 heard Resident B screaming out and informed RN 5. Housekeeper (HK) 10 and two CNAs reported Resident B's pain and discomfort to RN…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-10-20 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident with constipation, no recent bowel movements (BM), and reporting pain was monitored and treated timely resulting in the resident having a delay in treatment and requiring interventions under anesthesia for a severe fecal impaction for 1 of 5 residents reviewed for quality of care related to their bowel management program (Resident B), and the facility failed to ensure an effective protocol was put in place for the ongoing monitoring of 5 of 5 residents reviewed for quality of care related to the bowel management program (Residents B, E, F, G, and H). The Immediate Jeopardy (IJ) began on 9/24/25 when Resident B began to experience and complain of acute pain. His last recorded BM was 9/19/25 at 11:17 a.m. A Kidney, Ureter and Bladder (KUB) scan (a diagnostic scan of the abdominal area) was completed 9/23/25 and confirmed constipation. No orders or treatment were obtained after the results of the KUB. On 9/23/25 two doses of PRN…

  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
• Immediate jeopardy · Jcited before2023-08-04 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a resident's bilevel positive airway pressure (BIPAP) equipment (machine used to provide assistance during inspiration and expiration) was implemented upon hospital discharge, and failed to assess the resident's change in condition after not receiving a BIPAP for 3 days for 1 of 4 residents reviewed for quality of care (Residents B). Based on observation, record review, and interview, the facility failed to ensure a resident with a continuous positive airway pressure (CPAP) machine had physician orders and a plan of care for the CPAP machine for 1 of 4 residents reviewed for quality of care (Resident E). The immediate jeopardy began on [DATE] when Resident B returned from the hospital with orders for the resident to wear a BIPAP after the resident was in the intensive care unit (ICU) due to hypercapnia (elevated carbon dioxide [CO2] levels) on [DATE] requiring treatment with a BIPAP machine. The resident's BIPAP was not unboxed or…

  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
• Actual harm · G2025-07-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure a resident was assessed for and safely transferred in a mechanical lift resulting in actual harm when the resident fell from the mechanical lift sling during a transfer and sustained a fracture to the right tibia (bone in the lower leg) (Resident B), failed to ensure residents were appropriately transferred in mechanical lifts using the correct slings (Residents B and D), and to ensure a resident with multiple falls received updated interventions to prevent further falls (Resident C) for 3 of 4 residents reviewed for accidents. Findings include:1. Resident B’s record was reviewed on 7/22/25 at 11:23 a.m. Diagnoses on the resident’s profile included, but were not limited to, cerebral palsy (a group of neurological disorders that affect movement, muscle tone, and posture) and unspecified fracture of the upper end of the right tibia. A significant change Minimum Data Set (MDS) assessment, dated 7/1/25, indicated the resident had a…

  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 · Fcited before2025-12-15 · tag F0812 — failed to store, cook, and serve food safely — widespread
  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

  A. Based on observation, record review, and interview, the facility failed to ensure the kitchen dish machine temperature and sanitation logs, and the refrigeration temperature logs were maintained, and failed to ensure the paper towels at the kitchen handwash sink were maintained in a sanitary manner, for 1 of 3 kitchen observations. This deficient practice had the potential to affect 81 of 81 residents residing at the facility. B. Based on observation, interview, and record review, the facility failed to ensure resident hall trays were delivered in a sanitary manner for 1 of 1 meal service observation. Findings include:A. During the initial kitchen observation, on 12/9/25 at 9:55 a.m., the following was observed: 1. The November and December 2025 dish machine temperature and sanitation logs lacked documentation as follows: a. The November 2025 logs lacked documentation that the rinse temperature and sanitation readings were completed for the breakfast and lunch meals on 11/1/25, 11/6/25, 11/7/25, 11/11/25, 11/15/26, 11/16/25, 11/19/25, 11/20/25, 11/24/25, 11/25/25, 11/28/25,…

  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 · F2025-12-15 · tag F0881 — failed to use antibiotics responsibly — widespread
  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 follow antibiotic stewardship protocol program. This deficient practice had the potential to affect 81 of 81 residents residing at the facility. Findings include:On 12/12/25 at 1:30 p.m., review of the facility infection control program with the Infection Prevention Nurse (IP) indicated, the documentation lacked evidence of antibiotic stewardship tracking and trending. The program lacked documentation of education regarding any trending infections or prevention.12/12/25 at 1:45 p.m., during an interview the IP nurse, he indicated he had been tracking antibiotic stewardship once but had not continued.Review of the Centers for Disease Control and Prevention (CDC) webpage, The Core Elements of Antibiotic Stewardship, accessed online at: https://www.cdc.gov/antibiotic-use/hcp/core-elements/ . Improving antibiotic prescribing and use is critical to effectively treat infections, protect patients from harms caused by unnecessary antibiotic use, and combat antibiotic resistance.On 12/12/25 at 2:00 p.m., the Director of Nursing…

  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 · E2025-12-15 · tag F0552 — pattern
  Ensure that residents are fully informed and understand their health status, care and treatments.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure informed consent was obtained for the administration of psychotropic medications (drugs that affect the brain's chemical makeup to treat mental and emotional disorders), for 5 of 5 resident reviewed for unnecessary medications (Residents 53, 11, 10, 74, and 47). Findings include:1. Resident 53's record was reviewed on 12/10/25 at 1:55 p.m. The profile indicated the resident had been admitted to the facility on [DATE]. The resident was discharged from the facility on 12/10/25. The profile indicated the resident's diagnoses included, but were not limited to, major depressive disorder (a serious mood disorder causing persistent sadness, hopelessness, and loss of interest in activities, significantly impacting daily life for at least two weeks) and unspecified psychosis (a diagnosis used when someone has psychotic symptoms but there's not enough information for a specific diagnosis). A quarterly Minimum Data Set (MDS) assessment, dated 10/30/25,…

  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 · E2025-12-15 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
  Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interviews the facility failed to offer snacks to residents in the evening for 5 of 5 residents reviewed for snacks at bedtime (Residents 27, 28, 42, 87, and 91). Findings include:On 12/11/25 at 2:00 p.m., during resident council meeting the residents indicated they did not receive bedtime snacks and indicated they had a diagnosis of diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high). Review of the medical record of Residents 91, 28, 42, and 87 indicated each resident had a diagnosis of diabetes. On 12/11/25 at 2:15 p.m., during an interview the Administrator indicated the residents should be served snacks daily.On 12/11/25 at 2:23 p.m., during an interview the Director of Nursing (DON) indicated all residents should be offered a snack in the evenings especially the diabetic residents to maintain blood sugar levels through the night. On 12/11/25 during an interview Registered Nurse (RN) 11 indicated snacks were inconsistent. At times they had to go out and buy them for the residents. She indicated snacks should…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-12-15 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  A. Based on observation, record review, and interview, the facility failed to ensure a catheter (tube inserted into the bladder to drain urine) bag did not come in contact with an unclean surface for 1 of 1 residents reviewed for catheters (Resident 10). B. Based on observation, interview, and record review, the facility failed to ensure hand hygiene was performed during the medication pass for 4 of 4 residents reviewed on the medication pass (Residents 92, 93, 96, and 39). Findings include: A. On 12/9/25 at 11:13 a.m., Resident 10 was observed lying in bed. The resident's catheter draining bag was hanging from the side of the bed and was resting on the bottom leg bar of the bedside table. On 12/11/25 at 9:40 a.m., Resident 10 was observed lying in bed. The resident's catheter draining bag was hanging from the side of the bed and was resting on the bottom leg bar of the bedside table. Resident 10's record was reviewed on 12/10/25 at 1:35 p.m. Diagnoses on the resident's profile included, but were not limited to, vascular dementia (a decline in thinking skills caused by conditions…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-15 · tag F0605 — failed to not use drugs as a restraint — isolated
  Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
  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 physician signed and dated a pharmacy recommendation for psychotropic medications, failed to ensure behavior documentation was available to justify an increase in psychotropic medication dosage, and failed to ensure documentation to justify the declination of psychotropic medication dosage reductions for 3 of 5 residents reviewed for unnecessary medications (Residents 53, 11, and 10). Findings include:1. Resident 53's record was reviewed on 12/10/25 at 1:55 p.m. The profile indicated the resident's diagnoses included, but were not limited to, major depressive disorder (a serious mood disorder causing persistent sadness, hopelessness, and loss of interest in activities, significantly impacting daily life for at least two weeks). A quarterly Minimum Data Set (MDS) assessment, dated 10/30/25, indicated the resident had moderate cognitive deficit and received antidepressant medications (used to treat depression). A pharmacy recommendation, with…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-15 · tag F0628 — isolated
  Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a notice of transfer or discharge and bed hold policy was provided to the resident who was transferred to the hospital for 1 of 2 residents reviewed for hospitalization (Resident 12). Findings include:Resident 12's record was reviewed on 12/12/25 at 10:21 a.m. Census information indicated the resident was hospitalized from [DATE] to 10/10/25. A significant change Minimum Data Set (MDS) assessment, dated 9/3/25, indicated the resident was cognitively intact. A progress note, dated 10/6/25 at 3:40 a.m., indicated the resident was found sitting on the floor in his room. The resident denied pain and was assisted back to the chair. A progress note, dated 10/6/25 at 3:13 p.m., indicated the resident complained of pain to the right hip, and an x-ray was ordered by the physician. A progress note, dated 10/6/25 at 9:02 p.m., indicated the facility received the x-ray results and, and an order was received to send the resident to the emergency room (ER). A…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-15 · tag F0645 — isolated
  PASARR screening for Mental disorders or Intellectual Disabilities
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) (screening assessment to determine if a resident has a serious mental illness) was completed accurately for 1 of 2 residents reviewed for PASRR (Resident 2). Findings include:Resident 2's record was reviewed on 12/11/25 at 10:47 a.m. Census information indicated the resident was admitted to the facility on [DATE]. Diagnoses on the resident's profile included, but were not limited to, unspecified dementia (general term for a decline in cognitive function severe enough to interfere with daily life, affecting memory, thinking, and social abilities) of unspecified severity with other behavioral disturbance and unspecified psychosis (disconnection from reality with false beliefs and experiencing things that are not real) not due to a substance or known physiological condition. A Notice of PASRR Level I (screening required for all residents entering a long-term care facility to determine if there 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-15 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents were provided assistance with activities of daily living (ADLs) to ensure good hygiene for 3 of 4 residents reviewed for ADLs (Residents 10, 2, and 90). Findings include: 1. On 12/9/25 at 11:12 a.m., Resident 10 was observed lying in bed with untrimmed facial hair and long untrimmed fingernails with dark debris underneath them. On 12/9/25 at 9:40 a.m., Resident 10 was observed lying in bed with untrimmed facial hair and long untrimmed fingernails with dark debris underneath them. Resident 10's record was reviewed on 12/10/25 at 1:35 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 9/26/25, indicated the resident had a moderate cognitive impairment, required substantial/maximal assistance from staff with personal hygiene, had a diagnosis of moderate vascular dementia (a type of dementia caused by reduced blood flow to the brain, leading to cognitive impairment and memory loss), and indicated the resident had no…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-15 · tag F0756 — failed to review each resident's drug regimen — isolated
  Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a pharmacy recommendation was implemented as requested and approved by physician for 1 of 5 residents reviewed for unnecessary medications (Resident 47). Findings include: Resident 47's record was reviewed on 12/10/25 at 1:43 p.m. The profile indicated the resident's diagnoses included, but were not limited to, manic episode, severe, without psychotic symptoms (intense euphoria/irritability, high energy, racing thoughts, pressured speech, little sleep, and impulsive/reckless behavior (like spending sprees or risky sex) that significantly impairs functioning, but without hallucinations or delusions), depression (a serious mood disorder causing persistent sadness, loss of interest, and affecting how you think, feel, and live, impacting daily activities, sleep, appetite, and energy), and vascular dementia (a decline in thinking skills from reduced blood flow to the brain, often after strokes or from chronic conditions like high blood pressure,…

  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

“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.

Fines & penalties

$222,565 in federal fines across 1 penalty.

• $222,565 — penalty dated 2025-10-20

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to INFINITY HEALTHCARE CONSULTING — 69 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 →

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

CMS files one row per role, so the 4 rows in the source record cover these 3 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.

1 organizational owner 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 $1.5M paid to related parties — landlords or management companies under common ownership — equal to about 18% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IN