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Lane House, The

1000 Lane Ave, Crawfordsville, IN 47933 · Government - County · 60 certified beds · (765) 362-0007 Medicare & Medicaid certified

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Abuse/neglect citation on record (F0600) — cited Sep 2025Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation$175,065 in federal fines
Insights

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

Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2025
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $175,065 in federal fines (most recent 2026-01-27)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (1/5)
  • about 69% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Worth a closer look. This home's quality-measure rating runs 4 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

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
(765) 362-5789 · Call to confirm hours
Pharmacy
Walgreens0.6 mi
110 W Market St · (765) 361-9445 · Call to confirm hours
Grocery
205 Waynetown Rd · (765) 307-2944 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased8.3%11.0%15.4%better
Long-stay residents who lose too much weight19.7%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.6%1.1%2.0%better
Long-stay residents with depressive symptoms7.5%25.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury5.0%3.9%3.3%worse
Long-stay residents whose ability to walk worsened1.5%11.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication32.2%23.5%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.4%95.3%typical
Long-stay residents with pressure ulcers3.1%3.6%4.7%better
Long-stay residents with worsening bladder/bowel control29.0%23.3%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table12.5%13.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine94.6%79.0%79.4%better
Long-stay hospitalizations per 1,000 resident days1.211.611.67better
Long-stay outpatient ER visits per 1,000 resident days1.871.441.80typical

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

12.3%U.S. median 10.7%
Went back to hospital
0.19U.S. median 0.31
Therapy hours / resident / day
0.06hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.19 therapist hours per resident per day in 2026Q1 — more than 20% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.3%CMS range 7.6–17.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.871.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

RN hours/ resident / day
LPN hours/ resident / day
Aide hours/ resident / day
Total nurse hours/ resident / day
RN hoursweekends
51.1%
Total nursing turnover
66.7%
RN turnover

How full it usually is: this home is certified for 60 beds and averages 50.9 residents a day — about 85% occupied, or roughly 9 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.

Weekend coverage: total nurse staffing is 2.62 hrs/resident/day on weekends vs 3.12 on weekdays — 16% thinner on weekends. RN hours go from 0.48 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 51% 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

8
deficiencies at the latest standard inspection (2025-04-07)
6
at the previous standard inspection (2024-02-19)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.

  • Immediate jeopardy · J2026-01-27 · 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 cognitively intact resident with new onset altered mental status and vomiting was monitored and treated timely resulting in the resident having a delay in treatment and death for 1 of 3 residents reviewed for quality of care (Resident B). The immediate jeopardy began on [DATE] at 10:46 a.m. when a cognitively intact resident had new onset symptoms of coughing, coffee ground emesis, complaints of feeling drunk, and staggering while ambulating. The physician ordered a Complete Blood Count (CBC) that was not obtained. The record lacked documentation of the resident's condition on [DATE]. On [DATE] the resident had altered mental status, dizziness, abdominal pain, and his pulse was 128. The physician ordered a STAT (immediately) chest x-ray, a STAT abdominal x-ray, and STAT CBC with differential for cough, nausea, vomiting, abdominal pain, altered mental status, weakness, and dizziness. The STAT CBC was not obtained prior to the resident's death.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-27 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to immediately notify the resident's family, and/or emergency contact when a cognitively intact resident developed new onset altered mental status, vomiting, and physical decline for 1 of 3 residents reviewed for family notification (Residents B). Findings include:A confidential concern during the survey process indicated Resident B had a sudden change in his health status, and the physician ordered the resident to go to the hospital. Despite the resident continuing to get worse, the Executive Director (ED) and Director of Nursing (DON) refused to allow the resident to go. Resident B's clinical record was reviewed on [DATE] at 2:33 p.m. Diagnoses on Resident B's profile included prostate cancer, lung cancer, insulin dependent diabetes mellitus (DM) and gastro-esophageal reflux disease (GERD). A quarterly MDS (Minimum Data Set) assessment completed on [DATE], assessed Resident B as being cognitively intact. He was independent with eating, 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-27 · tag F0773 — isolated
    Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
    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 staff ordered, obtained, and tracked STAT (immediately) laboratory orders for 1 of 3 residents reviewed for completion of laboratory orders (Resident B). Findings include: A confidential concern during the survey process indicated Resident B had a sudden change in his health status, and the physician ordered the resident to go to the hospital. Despite the resident continuing to get worse, the Executive Director (ED) and Director of Nursing (DON) refused to allow the resident to go, and the resident subsequently died. Resident B's clinical record was reviewed on [DATE] at 2:33 p.m. Diagnoses on Resident B's profile included prostate cancer, lung cancer, insulin dependent diabetes mellitus (DM) and gastro-esophageal reflux disease (GERD). A nursing progress note, dated [DATE] at 10:46 a.m., indicated Resident B started coughing and had a small amount of coffee ground emesis. The resident complained of feeling drunk and staggering when he…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-09 · 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 record review and interview, the facility failed to accurately complete an elopement risk assessment for a vulnerable resident who was found outside the facility, on the grass after falling out of his wheelchair, without the knowledge of staff for 1 of 3 residents reviewed for neglect (Resident C). The deficient practice was corrected by 9/8/25 prior to the start of the survey and was therefore past noncompliance. Findings include:A nursing progress note, dated 9/7/25 at 3:35 p.m., indicated that emergency medical services (EMS) were at the facility. A resident had gotten outside without being seen and had fallen from his wheelchair. EMS had arrived to the facility at 3:32 p.m. and indicated they had gotten a call around 3:28 p.m. that a person was crawling in the grass on the side of the facility. Nursing staff reported last seeing Resident C around 3:00 p.m. A different resident had indicated she saw a visitor coming or going who had left the door open for Resident C to go outside. 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · Fcited before2025-04-07 · 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, interview, and record review, the facility failed to ensure the low temperature dish machine (a commercial dishwashing machine that relies on chemical sanitizers, rather than high temperatures, to sanitize dishes, typically operating at temperatures between 120° Fahrenheit [F] and 140 F) wash and rinse temperatures met minimum standards and the March 2025 logs for the dish machine temperatures were completed for 1 of 2 kitchen observations. This had the potential to affect all residents who consumed food or liquids from the kitchen. B. Based on observation, interview, and record review, the facility failed to ensure the March 2025 logs for the sanitizer solution bucket (a container filled with a sanitizer solution [like bleach or a similar chemical] used to reduce germs on surfaces, often wiping cloths or equipment, to safe levels), freezer, refrigerator, and dinner meal food temperatures were completed for 1 of 2 kitchen observations. This had the potential to affect all residents who consumed food or liquids from the kitchen. C. Based on observation,…

    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 · E2025-04-07 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make 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

    Based on observations, interview, and record review the facility failed to ensure a sanitary environment was maintained for residents during meal service for 2 of 2 random observations. This had the potential to affect all residents on the [NAME] Hall consuming food during the use of cleaning supplies. Findings include: On 4/01/25 at 12:10 p.m., during observation of the noon meal service on the [NAME] Hall, observed Employees 8 and 3 cleaning rooms and mopping floors while drinks and food trays were being passed to residents. On 4/01/25 at 12:30 p.m., observed Employee 3 cleaning handrails outside of the residents rooms while residents were eating. On 4/01/25 at 12:18 p.m., during interview with Housekeeping Supervisor she indicated she had instructed the staff to remove carts when meals were being served. She indicated the housekeepers were not permitted to clean residents rooms or hall area when meals were being served. On 4/1/2025 at 1:48 p.m., the Administrator provided a document, titled, Housekeeping Services, dated 6/29/21, and indicated it was the policy currently being…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-07 · 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 observation, record review, and interview, the facility failed to ensure falls were documented, interventions implemented, and a call light was within the resident's reach for 1 of 2 residents reviewed for falls (Resident 29). Findings include: During an observation, on 4/1/25 at 11:05 a.m., Resident 29 was in his recliner with no call light within his reach. The call light was observed at the end of his bed. At the same time, the resident indicated he used the call light to request assistance when needed, and it was over there on the bed somewhere. When queried how he used the call light when it was on the bed, the resident indicated, I don't. The resident requested to lay back down in bed. During an interview, on 4/1/25 at 12:07 p.m., Resident 29's daughter indicated he had fallen a lot since being at the facility. He fell often at home too. The resident used the call light to ask for help and knew how to use it, but he sometimes got up without assistance. The resident had fallen earlier in the day on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-07 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to address a significant weight discrepancy for 2 of 4 residents reviewed for nutrition and the facility failed to obtain daily weights for 1 of 4 residents reviewed for weights (Residents 27, 17, and 21). Findings include: 1. Resident 27's record was reviewed on 4/2/25 at 1:45 p.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic combined systolic (congestive) and diastolic (congestive) heart failure (a long-term condition where the heart's ability to pump blood effectively impairs both systole [contraction] and diastole [relaxation], leading to fluid buildup and other symptoms) and cardiomegaly (an enlarged heart). A quarterly Minimum Data Set (MDS) assessment, dated 2/26/25, indicated the resident had severe cognitive impairment and indicated the resident had weight loss in the last 6 months and was not on a weight loss regimen. A care plan, dated 1/14/25, indicated the resident had unplanned/unexpected weight…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-07 · 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

    Based on observations, interviews, and record review, the facility failed to ensure proper storage of respiratory equipment for 1 of 2 residents reviewed for respiratory care (Resident 14). Findings include: 1a. On 4/1/25 at 11:21 a.m., Resident 14's unbagged nebulizer (turns liquid medicine into a mist that can be easily inhaled) mouthpiece and tubing were observed laying on top the nebulizer machine. The resident was sitting in her wheelchair next to her bed. 1b. On 4/1/25 at 2:38 p.m., Resident 14 was sitting up in her wheelchair watching T.V. and her unbagged nebulizer mouthpiece and tubing were observed laying on top of the nebulizer machine on her bedside table. 1c. On 4/2/25 at 9:50 a.m., Resident 14 was resting in bed and her nebulizer mouthpiece and tubing was observed sitting on top of her nebulizer machine in a clear plastic trash bag. The trash bag was not labeled with the resident's name or date. 1d. On 4/3/25 at 10:28 a.m., Resident 14's unbagged nebulizer mouthpiece and tubing were observed to be sitting on top of her nebulizer machine. The resident indicated that she…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-07 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 behaviors were documented to support the declination of a medication gradual dose reduction (GDR) for 1 of 5 residents reviewed for unnecessary medications (Resident 36). Findings include: Resident 36's record was reviewed on 4/2/25 at 10:55 a.m. Diagnoses on the resident's profile included, but were not limited to, major depressive disorder single episode and unspecified mild anxiety disorder. Progress Notes, dated December 2024, lacked documentation of behaviors, including restlessness. A physician's order, dated 12/31/24, indicated administer Ativan (antianxiety medication) 0.25 milligrams (mg) via gastrostomy tube (g-tube) twice daily for anxiety. A physician's order, dated 12/31/24, indicated administer sertraline (antidepressant medication) 25 mg via g-tube once daily for depression. Progress Notes, dated January 2025, lacked documentation of behaviors, including restlessness. A Medication Administration Record (MAR), dated February 2025, indicated monitor and document behaviors of yelling out and disturbing…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-07 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure keys to the medication room were kept in an area only accessible to nursing staff, food was not kept in the medication room, multi-use medication containers were dated when opened, and insulin was disposed of once it was past the use by date for 1 of 1 medication rooms reviewed and 1 of 2 medication carts reviewed (Residents 33 and 12). Findings include: 1. During an observation, on 4/7/25 at 10:19 a.m., the Director of Nursing (DON) removed keys from an unsecured drawer at the nurse's station and unlocked the medication room. The nurse's station was not locked or secured and was accessible to staff and visitors. The keys obtained from the unsecured drawer unlocked the narcotic and refrigerated emergency drug kits (EDKs) in the medication room. A container of peanut butter bars was observed on the counter in the medication room. A medication bottle contained three vials of Aplisol (tuberculosis testing solution) and was stored in the refrigerator. One of the vials of Aplisol was opened. There was 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · Dcited before2024-07-29 · 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

    Based on record review, observation, and interview, the facility failed to ensure a dependent resident had adequate supervision, a safe environment, and was provided care to remain free from injuries of unknown origin for 1 of 3 residents reviewed for accidents (Resident B). Finding includes: On 7/26/24 at 10:45 a.m., a review of an Indiana Department of Health (IDOH) Reportable Incident document, dated 7/6/24 at 6:01 a.m., indicated Resident B was found with bruising to bilateral face and swelling to the nose. She also had a skin tear noted to her left forearm. The type of injury that was noted on the document indicated bruising of unknown etiology. A head-to-toe assessment was completed, and the resident was sent to the emergency room for evaluation and an investigation was initiated. On 7/26/24 at 11:05 a.m., Resident B was observed sitting in a wheelchair outside of her room across from the nurses' station. No bruising was noted to her face at this time, but she did have a foam dressing on her left hand. The resident was unable to communicate about why she had a dressing on her…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-29 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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 resident's gastrostomy tube (g-tube-a tube inserted through the belly that brings nutrition directly to the stomach) was maintained in a clean and sanitary condition, for 1 of 2 residents reviewed for g-tube (Resident C). The deficient practice was corrected on 7/17/24, prior to the start of the survey, and was therefore past noncompliance. Findings include: A complaint intake document, dated 7/12/24, indicated Resident C had been seen in the emergency room (ER) of the local hospital. During the physical assessment, live maggots (fly larvae) were found crawling around his g-tube site. Resident C's record was reviewed on 7/26/24 at 11:15 a.m. The profile indicated the resident's diagnoses included, but were not limited to, history of malignant neoplasm (a cancerous tumor) of the lip, oral cavity and pharynx (a hollow, muscular tube inside the neck that starts behind the nose and opens into the larynx [the area of the throat containing the vocal cords and used for breathing, swallowing, and talking] and esophagus),…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · Ecited before2024-02-19 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure hair restraints (hair covering and nets, beard restraints, and clothing that cover body hair) were worn in the kitchen during meal service and preparation during 2 of 2 kitchen observations. Findings include: 1. On 2/13/24 at 11:49 a.m., during observation of the lunch meal service in the main dining room, an area in the kitchen was observed to be marked with tape, across the floor, which designated the area staff could not go beyond, without a hair restraint. Licensed Practical Nurse (LPN) 4 was observed entering the kitchen area, beyond the designated area, to retrieve meal trays without a hair restraint. At the same time, the Dietary Manager was observed standing in the kitchen, beyond the designated area, with uncovered facial hair. During an interview, on 2/13/24 at 12:01 p.m., the Dietary Manager indicated that both he and LPN 4 were past the designated area of the kitchen and should have been wearing hair restraints. 2. During observation of pureed food (a way to change the texture of solid food…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-19 · 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 observation, record review, and interview, the facility failed to ensure a resident was transferred properly for 1 of 1 resident reviewed for accidents (Resident 14). Findings include: On 2/13/24 at 2:10 p.m., a local police officer was observed entering Resident 14's room with the resident's family member. During an interview, on 2/13/24 at 2:12 p.m., the Executive Director (ED) indicated there had been an allegation of abuse from a resident which indicated a staff had hit her in the right breast during care. The facility had sent in a State reportable incident form and begun an investigation. They also contacted the local police to get statements and investigate. Resident 14's record was reviewed on 2/19/24 at 9:55 a.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD-a group of diseases that cause airflow blockage and breathing-related problems), unspecified dementia (the impaired ability to remember, think, or make…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-19 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    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 they were free of a medication error of 5% or higher with an error rate of 6.67% for 1 of 5 residents observed for medication administration (Resident 24). Finding includes: During an observation of medication administration, on 2/15/24 at 9:30 a.m., Registered Nurse (RN) 3 proceeded into the main dining room where Resident 24 was standing. RN 3 had a medication cup with the resident's medication in it. Resident 24 was standing by a table with her walker when RN 3 set down the cup of pills on the table. The nurse obtained the resident's blood pressure and indicated to Resident 24 these were her morning pills and that she would be back in a minute because she needed to check on her blood pressure parameters due to her low blood pressure reading. RN 3 walked away from the resident and exited the dining room with 2 pills still in the medication cup minus her blood pressure medication. RN 3 did not observe the resident take her medication before she left the dining room. Resident 24's record was reviewed…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-19 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, the facility failed to ensure the medical record of medication administration was accurately documented for 1 of 5 residents reviewed (Resident 31). Findings Include: On 2/15/24 at 10:52 a.m., the medical record of Resident 31was reviewed. The resident was admitted to the facility on [DATE]. Diagnosis included, but were not limited to, chronic obstruction obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems) COPD, aphasia (a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension) following a cerebral infarction (a stroke which is when blood flow to a part of your brain is stopped either by a blockage or the rupture of a blood vessel), anxiety disorder (a feeling of fear, dread, and uneasiness which might cause you to sweat, feel restless and tense, and have a rapid heartbeat), malignant neoplasm of right female breast (cancerous tumor), depression (an illness…

    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 · D2024-02-19 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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 proper handling of medication patches during the medication administration pass for 2 of 5 residents reviewed during medication administration (Residents 9 and 26). Findings include: 1. During a medication administration observation, on 2/15/24 at 9:44 a.m., RN 3 placed a Lidocaine (pain relief medicated patch) external patch onto Resident 9's right shoulder. RN 3 did not have gloves on when removing the patch from the packaging or when placing the patch onto the resident's shoulder. Resident 9's record was reviewed, on 2/15/24 at 1:20 p.m. The profile indicated the resident diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe) and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one sided weakness, but without complete paralysis). An annual…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-19 · tag F0908 — failed to keep essential equipment working — isolated
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview the facility failed to maintain all mechanical equipment was kept in safe operating condition for 2 of 2 observations of the laundry service area. Findings Include: On 2/19/24 at 11:02 a.m., during routine observation of the laundry service area, two large fans were observed. The fan blades and the fan cage covering the blades were coated in a thick layer of grey lint. On the floor behind washers were a large amount of grey lint and debris. Lint traps in two dryers contained a moderate amount of lint on the screens. The cleaning logs indicated the lint traps were cleaned frequently. The lint on the fans and behind the washers created a risk for fire hazard. On 2/19/24 at 1:30 p.m., during an interview with the Administrator indicated the fans and floors of the laundry area must be kept clean and free of lint. On 2/19/2024 at 11:30 a.m., the Assistant Director of Nursing (ADON) provided a document titled, Laundry Services- General Policy, dated 2/12/20, and indicated it was the policy currently being used by the facility. The policy indicated,…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-08 · tag F0572 — isolated
    Give residents a notice of rights, rules, services and charges.
    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 resident's rights had been reviewed with the members of the Resident Council, during the monthly scheduled meetings, for 3 of 3 residents who attended the Resident Council interview. Findings include: On 12/5/22 at 1:05 p.m., after obtaining the approval of the Resident Council President, the minutes from the Resident Council meetings, dated September 2022, October 2022, and November 2022, were reviewed. The minutes lacked documentation related to the resident's rights ever having been discussed at the during the Resident Council meetings. During the Resident Council interview, on 12/5/22 at 1:37 p.m., Resident 7, who identified herself as the Resident Council President indicated she was not aware of any Resident Council meeting where the resident's rights had been discussed. At the same time, Resident 8 indicated she had never heard any discussion of the resident's rights at any of the Resident Council meetings she had attended. During an interview, on 12/5/22 at 1:41 p.m., Resident 39 indicated he was not 100%…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-08 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record reviews, the facility failed to ensure a resident had the right to be free from physical abuse and coercion when she was forcibly given a shower against her will for 1 of 1 resident reviewed for abuse (Resident 19). Findings include: On 11/30/22 at 2:31 p.m., Resident 19 was initially observed. She was reclined in her bed, with the head of her bed elevated as she watched T.V. Although she was hard of hearing, she was able to answer questions appropriately, and carried on a cohesive conversation. She was observed to have a large, faded bruise which was purple/black and green around the edges located on her left forearm just below her elbow. When asked about what happened to her arm, Resident 19 sighed deeply, shook her head and pinched her lips together as she made a frustrated frown. She indicated, it was September 11th, I remember because of the date, they tricked me into taking a shower. She indicated, those girls, knew she did not like to take a shower because it hurt to move her arms and shoulder. She always preferred to take 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · D2022-12-08 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure orders for a hand splint were re-initiated upon return from the hospital and implemented to prevent the potential for worsening contractures and skin break down for 1 of 1 resident reviewed for Range of Motion (ROM) services (Resident 14). Findings include: On 11/30/22 at 11:17 a.m., Resident 14 was initially observed. She was reclined in a Broda chair (specialty reclining wheelchair) beside her bed. Her eyes were closed. Her hands were observed closed into fists and rested on her lap. There was a mesh bag which hung on her wall with what appeared to be a soft padded brace. During an interview on 11/30/22 at 3:22 p.m., Resident 14's family member indicated they were concerned about Resident 14's hands which had started to pull together into tight fists. She was supposed to have something on her hands to prevent her fingernails from digging into her palms, but when the family member visited they never saw them in place. On one…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-08 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record reviews, the facility failed to identify a resident, (Resident D) at a higher risk for the development of serious urinary tract infections (UTIs) due to her history of UTIs and the presentation of her intellectual/developmental disabilities which at baseline, often closely resembled common symptoms of a UTI, which resulted in 2 of 3 hospitalizations for sepsis, secondary to UTIs. This deficient practice had the potential to effect 1 of 2 residents reviewed for UTIs. Findings include: On 11/30/22 at 11:42 a.m., Resident D was observed. She sat in a wheelchair in the hallway outside of her room. She made independent attempts to ambulate with her chair, and slowly rolled herself up and down the main hallway. She was unable to answer simple questions, and was observed to intermittently cough weakly, moaned, and groaned as if crying. She stopped in the middle of the hall, unaware of other's paths that may have been obstructed. She fiddled with the slippers on her feet. Her eyes were open but dull, and here eye-lids appeared heavy and dropped.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-08 · 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

    Based on observation, record review, and interview, the facility failed to ensure a nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) mask was stored properly for 1 of 1 residents reviewed for respiratory (Resident 28). Findings include: During an initial observation of the resident, on 12/1/22 at 1:49 p.m., the resident's nebulizer mouthpiece and tubing were observed unbagged and sitting on her bed side table (BST). A liquid substance was observed in the medication container of the nebulizer. During a random observation, on 12/2/22 at 10:56 a.m., the resident's nebulizer mouthpiece and tubing were observed unbagged and sitting on her BST. During a random observation, on 12/5/22 at 9:56 a.m., the resident's nebulizer mouthpiece and tubing were observed unbagged and sitting on her BST. Resident 28's record was reviewed on 12/6/22 at 10:57 a.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-08 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record reviews, the facility failed to ensure the general cleanliness of food storage areas was maintained and failed to ensure the air conditioning (AC) grated vents were cleaned to prevent potential for contamination of uncovered foods for 1 of 2 kitchen observations. These deficient practices had the potential to effect 42 of 42 residents served from the kitchen. Findings include: On 11/30/22 at 9:52 a.m., an initial kitchen tour was conducted with the Kitchen Manager (KM). Upon entrance to the kitchen, an uncovered metal rack of individualized pre-prepared dessert bowls were observed. Each bowl was also uncovered. The KM indicated it was fruit pie, which had been prepared for that day's lunch. The AC ventilating system, which hung from the kitchen ceiling was felt to be blowing cool air, and the grated vent openings were observed to be rusted, and covered with copious grey, fuzzy dust/debris which was observed to undulate in the forced air. The vents, which were located throughout all areas of the kitchen were observed to be built up 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • No harm found · Ccited before2025-04-07 · tag F0732 — widespread
    Post nurse staffing information every day.
    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 accurate staffing sheets were posted daily for 3 of 5 days during the recertification survey. Findings include: During an observation, on 4/01/25 at 12:19 p.m., the staffing sheet posted on the wall outside of the nurses' station was dated correctly, but the posting lacked documentation of the total number of the facility census and the name of the facility. During an observation, on 4/2/25 at 9:27 a.m., the staffing sheet posted on the wall outside of the nurses' station, was dated on the top half of the sheet for 4/2/25 and the bottom half for 4/3/25, but the posting lacked documentation of the total number of the facility census and the name of the facility. During an interview, on 4/2/25 at 9:30 a.m., the Director of Nursing (DON) indicated she was not aware the staffing sheet posted was not completed accurately. She indicated the scheduler was responsible for making sure the posting was completed accurately. The DON indicated she would post the staffing sheet in the morning if the scheduler wasn't…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • No harm found · Ccited before2022-12-08 · tag F0732 — widespread
    Post nurse staffing information every day.
    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 nurse staffing information was posted daily for 1 of 7 observations of staff postings. Finding includes: On 11/30/22 at 12:37 p.m., observation of the nurse staffing information posted by the nurses' station was dated 11/7/22. On 11/30/22 at 4:06 p.m., observation of the nurse staffing information posted by the nurses' station was dated 11/30/22. The Director of Nursing (DON) indicated she had just updated and posted the nurse staffing information this afternoon and the nurse staffing information posting should have been updated daily. It just got missed. On 12/1/22 at 9:05 a.m., the Administrator provided and identified a document as a current facility policy, titled Life Care Centers of America Staffing, dated 7/27/22. The policy indicated, .Policy .The facility maintains adequate staff on each shift to meet residents' needs, posts daily staffing data and furnishes staffing information to the state as specified in the Federal regulations .Procedure: .2. The facility posts daily staffing information…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$175,065 in federal fines across 1 penalty.

  • $175,065 — penalty dated 2026-01-27

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 LIFE CARE CENTERS OF AMERICA — 194 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 →

RatingThis homeChain avg
Overall 2 of 53.4-1.4 vs chain
Health inspection 1 of 52.8-1.8 vs chain
Staffing 1 of 53.3-2.3 vs chain
Quality measures 5 of 54.5+0.5 vs chain
The other 193 homes this chain runs (chain average 3.4★, per CMS)
1 of 5Garden Terrace At Overland ParkOverland Park, KS 1 of 5Hammond-Whiting Care CenterWhiting, IN 1 of 5Life Care Center Of AndoverAndover, KS 1 of 5Life Care Center Of Cape GirardeauCape Girardeau, MO 1 of 5Life Care Center Of GrayGray, TN 1 of 5Life Care Center Of HixsonHixson, TN 1 of 5Life Care Center Of Mount VernonMount Vernon, WA 1 of 5Life Care Center Of RenoReno, NV 1 of 5Life Care Center Of Sierra VistaSierra Vista, AZ 1 of 5Life Care Center Of The WillowsValparaiso, IN 1 of 5Life Care Center Of TucsonTucson, AZ 1 of 5Life Care Center of Coeur d'AleneCoeur d'Alene, ID 1 of 5Life Care Center of ElkhornElkhorn, NE 1 of 5Life Care Center of Hilton HeadHilton Head Island, SC 1 of 5Life Care Center of OmahaOmaha, NE 1 of 5Life Care Center of PlainwellPlainwell, MI 1 of 5Life Care Ctr Of LawrencevilleLawrenceville, GA 1 of 5Rensselaer Care CenterRensselaer, IN 2 of 5Canon Lodge Care CenterCanon City, CO 2 of 5Darcy Hall Of Life CareWest Palm Beach, FL 2 of 5Desert Cove Nursing CenterChandler, AZ 2 of 5Evergreen Nursing HomeAlamosa, CO 2 of 5Garden Terrace Healthcare Center of HoustonHouston, TX 2 of 5Hallmark ManorFederal Way, WA 2 of 5Life Care Center Of Altamonte SpringsAltamonte Springs, FL 2 of 5Life Care Center Of AthensAthens, TN 2 of 5Life Care Center Of BridgetonBridgeton, MO 2 of 5Life Care Center Of BrookfieldBrookfield, MO 2 of 5Life Care Center Of ClevelandCleveland, TN 2 of 5Life Care Center Of ColumbiaColumbia, SC 2 of 5Life Care Center Of Coos BayCoos Bay, OR 2 of 5Life Care Center Of Federal WayFederal Way, WA 2 of 5Life Care Center Of GrandviewGrandview, MO 2 of 5Life Care Center Of KirklandKirkland, WA 2 of 5Life Care Center Of Merrimack ValleyBillerica, MA 2 of 5Life Care Center Of Morgan CountyWartburg, TN 2 of 5Life Care Center Of PuyallupPuyallup, WA 2 of 5Life Care Center Of Red BankChattanooga, TN 2 of 5Life Care Center Of South Las VegasLas Vegas, NV 2 of 5Life Care Center Of TullahomaTullahoma, TN

Showing 40 of 193; 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 / managerTypeRoleSince
ENGELS, ERINIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 11/01/2018
GENTRY, MARKIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 01/12/2022
STARKEY, TYLERIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 08/01/2020
WAITE, JOHNIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 08/01/2020
WHICKER, TIMOTHYIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 01/12/2022
FENOUGHTY, DEANNAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 07/10/2023
CONSOLIDATED RESOURCES HEALTH CARE FUND I LPOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2018
LIFE CARE CENTERS OF AMERICA, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/12/2025
FLETCHER, TODDIndividualOPERATIONAL/MANAGERIAL CONTROLsince 11/01/2018
HENRY, TERRYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 11/01/2018
LAY, LISAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 11/01/2018
MCGOWEN, GLORIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/12/2018
PRESTON, AUBREYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 03/06/2025
PRESTON, FORRESTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2018
SWANKER, RICHARDIndividualOPERATIONAL/MANAGERIAL CONTROLsince 11/01/2018
TAN, EUGENE FRANCISIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/18/2020
THURMOND, JOANIndividualOPERATIONAL/MANAGERIAL CONTROLsince 11/01/2018
ZIEGLER, JAMESIndividualOPERATIONAL/MANAGERIAL CONTROLsince 11/01/2018
CROSS, CINDYIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNFsince 02/18/2025
HENDRICKS COUNTY HOSPITALOrganizationADP OF THE SNFsince 02/20/2025

CMS files one row per role, so the 32 rows in the source record cover these 20 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.

3 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.

$5.0M
Net patient revenuemost recent cost report
+2.1%
Operating marginrevenue minus expenses
$3.4M
Related-party expense69% of expenses
Who pays — share of resident-days
Medicaid 78%Medicare 3%Other / private 19%

About 78% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $3.4M paid to related parties — landlords or management companies under common ownership — equal to about 69% 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

$297per resident / day
operating cost
$9,021per month
≈ monthly operating cost
$303per day
avg. revenue, all payers

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

What families pay in IN

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Indiana Medicaid page.

Typical monthly cost in Indiana
$8,943/mo
Nursing home (semi-private)
$10,326/mo
Nursing home (private)
$5,639/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 155477. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-07, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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