Riverside Village
1400 W Franklin St, Elkhart, IN 46516 · Non profit - Corporation · 97 certified beds · (574) 522-2020 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2023
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (65%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 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 3 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 improved from 1 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 2.7% | 11.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.7% | 5.5% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 1.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 5.6% | 25.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.5% | 3.9% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 6.6% | 11.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 16.3% | 23.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 95.5% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.7% | 3.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 21.6% | 23.3% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.7% | 13.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.9% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 81.5% | 79.0% | 79.4% | typical |
‡ 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.
Therapy staffing: this home’s payroll records show 0.13 therapist hours per resident per day in 2026Q1 — more than 10% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 2% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not 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 SNF | 10.7%CMS range 6.4–18.4 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | not 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 discharge | not 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 discharge | not 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 identified | not 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 setting | not 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 discharge | not 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 stay | not 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 worsened | not 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 hospitalization | not 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 SNFs | 0.96 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 97 beds and averages 64.1 residents a day — about 66% occupied, or roughly 33 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 3.43 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.95 hrs/resident/day on weekends vs 3.63 on weekdays — 19% thinner on weekends. RN hours go from 0.56 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 65% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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 unchanged from the previous inspection. 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.
27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.
- Potential for harm · Dcited before2026-06-26 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews, the facility failed to assess skin related to a blackened toe for 1 of 3 residents (Resident G) and failed to sign for medications immediately after administration for 2 of 3 residents reviewed for changes in condition. (Residents E and F) Findings include: 1. A records review was completed on 6/25/2026 at 9:33 A.M. for Resident G. Diagnoses included, but were not limited to, hemiplegia/hemiparesis following cerebral infarction left non-dominant side, chronic kidney disease stage 3, unspecified chronic obstructive reflux uropathy, unspecified severe protein calorie malnutrition, and adult failure to thrive. A Quarterly Minimum Data Set (MDS) assessment, dated 4/21/2026, indicated the resident exhibited a moderate cognitive deficit, had not exhibited behaviors of refusal of care, had impaired range of motion on his upper and lower extremities on one side, was dependent on staff for transfer needs, required moderate assistance for eating and had an indwelling urinary catheter and a colostomy. A current Care Plan, initiated 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.
- Potential for harm · E2026-02-24 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to readily provide grievance forms for residents to place an anonymous grievance for 65 of 65 residents.Finding includes:During a Resident Council meeting, on 2/19/2026 at 2:30 P.M., 12 of 12 residents in attendance indicated grievance forms were located behind the nursing station and they had to ask a staff member for a grievance form if they wanted to file a grievance. The residents indicated they were unable to file a grievance anonymously.During an observation and interview, on 2/19/2026 at 3:13 P.M., the Executive Director indicated grievance forms were located behind the nurse's station, but were not available for residents to obtain anonymously without asking for staff assistance. The Executive Director looked at one of the nurse's stations and there were no forms available in the plastic wall hanger behind the nurse's station. The Executive Director indicated the residents needed to ask for a grievance form.A policy was provided, on 2/24/2026 at 9:45 A.M., by the Executive Director. The policy titled, Resident Concerns…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-02-24 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 prepare, store and serve food in a sanitary manner in 1 of 1 kitchen and 1 of 2 dining halls. (Main Dining Hall) This had the potential to affect 62 of 64 residents who receive meals from the kitchen and 18 of 18 residents who ate in the Main Dining Hall. Findings include:1 An initial tour of the kitchen with the Dietary Manager (DM) was completed on 2/18/2026 at 9:39 A.M. During the tour, the following was observed:-A two door upright freezer had a thick black substance on the rubber seal and the stainless steel portion where the seal met the stainless steel. -The walk-in cooler had a container of concentrated beef broth base with a best by date of 12/2025.-The freezer had four unlabeled house made shakes without a date indicating when the shakes had been made or needed to be used by or discarded.- A large area of a dark brown substance was observed on the side of the stovetop and the side of the oven.During an interview on 2/18/2026 at 9:54 A.M., the DM indicated the thick black substance was mildew. 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.
- Potential for harm · Dcited before2026-02-24 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to follow a physician's order to notify the provider of a 3 pound weight gain in 1 day for 1 of 3 residents reviewed for edema. (Resident 33) Finding includes: A record review for Resident 33 was completed on 2/19/2026 at 12:52 P.M. Diagnoses included, but were not limited to, chronic congestive heart failure (CHF). A Quarterly Minimum Data Set (MDS) assessment, dated 1/12/2026, indicated Resident 33 received a diuretic daily for CHF. A Physician's Order, dated 1/14/2026, indicated Resident 33 was to be weighed daily and the physician was to be called for a gain of 3 pounds in one day or 5 pounds in one week. On 2/8/2026 the Medication Administration Record (MAR) indicated the resident's weight was 197 pounds and on 2/9/2026 it was 200.1 pounds, a gain of 3.1 pounds in one day. The MAR indicated the physician was not notified of the 3.1 pound gain. During an interview on 2/24/2026 at 10:09 A.M. the DON indicated the physician should have been notified of the weight gain. She further indicated the facility did not have 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.
- Potential for harm · D2026-02-24 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
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 showers were provided for 1 of 6 residents reviewed for ADL (Activities of Daily Living) care. (Resident 21)Finding includes:On 2/18/2026, at 2:39 P.M., Resident 21 was observed in the Memory Care unit dayroom with greasy, unkempt hair. On 2/20/2026, at 11:30 A.M., Resident 21 was observed in the dayroom of the Memory Care unit with her hair still unkempt and greasy.On 2/23/2026 at 10:06 A.M. Resident 21 was observed in the Memory Care unit while exiting her room; her hair appeared disheveled and greasy.The clinical record of Resident 21 was reviewed on 2/19/2026 at 12:54 P.M. The resident's diagnoses included, but were not limited to: Alzheimer's disease, a displaced fracture of the base of the neck of the left femur, paranoid schizophrenia, diabetes mellitus, osteoporosis, personal history of intraductal carcinoma in situ of the left breast, anemia, severe protein-calorie malnutrition, retention of urine, cognitive or emotional deficit following cerebral infarction, depression, dysphagia, anorexia,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-24 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to provide behavioral interventions for 1 of 2 residents reviewed for behavioral-emotional issues. (Resident 19) Finding includes:During an observation, on 2/18/2026 at 10:22 A.M., Resident 19 had a very strong odor of urine in her room.During an observation, on 2/18/2026 at 11:43 A.M., Resident 19 was observed to be hoarding paper towels from the dispenser in the dining room. Resident 19 was pulling paper towels, folding them and placing them under her arm. The stack was approximately three inches thick. Staff observing the behavior had not intervened with this behavior.During an observation, on 2/18/2026 at 1:32 P.M., Resident 19 was observed in dining room with a very strong smell of urine.During an observation, on 2/18/2026 at 3:26 P.M., Resident 19 was sitting in the dining room, and a strong scent of urine could be smelled.During an observation, on 2/19/2026 at 12:49 P.M., Resident 19's room had a strong smell of urine.During an observation, on 2/18/2026 at 12:11 P.M., Resident 19 was observed wearing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-24 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure required blood monitoring was completed timely for 1 of 5 residents reviewed for unnecessary medications. (Resident 29)Finding includes: The clinical record for Resident 29 was reviewed on 2/19/2026 at 2:00 P.M. The resident's diagnoses included, but were not limited to: dementia, psychosis, anxiety, anemia, atherosclerotic heart disease, severe protein-calorie malnutrition, spondylosis, hypertension, dysphagia, hydronephrosis, hypotension, obstructive and reflux uropathy and atrophy of the kidney.A Quarterly Minimum Data Set (MDS) assessment, dated 1/19/2026, indicated the resident received antianxiety, antidepressant, anticonvulsant and hypnotic medications.A current Care Plan, initiated 11/14/2025, indicated Resident 29 was at risk for adverse side effects related to use of anticonvulsant or antiseizure medication and interventions included but were not limited to: labs as ordered.Current Physician's orders included Divalproex (a prescription medication used to treat epilepsy (seizures), manic episodes associated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-26 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a resident was assessed, monitored and treated for pain, which resulted in the resident calling 911 and going to the hospital due to her pain, for 1 of 3 residents reviewed for pain management, (Resident B). Finding includes: On 6/23/25 at 9:14 A.M., Resident B's clinical record was reviewed. The resident was admitted to the facility for one day, following an eight day hospital admission from home. The resident diagnoses included, but were not limited to, left shoulder and left arm pain, multiple sclerosis, spastic hemiplegia to the right side, polyneuropathy, chronic pain, venous insufficiency, overactive bladder, and spinal enthesopathy of the cervical region. Review of the Resident B's hospital records indicated the resident had been admitted for complaints of left shoulder, neck and left arm pain. The physician's assessment following testing indicated the resident had . a less that 50% partial-thickness partial width articular surface tear of the supraspinatus and infraspinatus tendons (a significant injury to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-03-06 · tag F0622 — patternNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure discharge documentation was obtained and/or complete upon discharge for 5 of 6 residents reviewed for transfer/discharge. (Residents F, H, J, K and L) Finding include: 1. The record for Resident F was reviewed on 3/5/2025 at 10:48 A.M. Diagnoses included, but were not limited to low back pain, Cerebral palsy, obesity and contracture to the right upper arm. A Social Service Progress Note, dated 2/11/2025 at 10:20 A.M., indicated the following: Discharge to preferred address. Resident was alert and oriented. All personal possessions sent with the resident. Resident F's physician orders lacked an order to discharge the resident. During an interview, on 3/6/2025 at 9:56 A.M., the Regional Director of Clinical Services (RDCS) indicated there should have been a physician's order to discharge the resident home. 2. The record for Resident H was reviewed on 3/5/2025 at 2:34 P.M. Diagnoses included, but were not limited to anemia, diabetes, and cellulitis…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-11-27 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview and record review, the facility failed to store food in a safe and sanitary manner in 1 of 1 kitchen observed. The deficient practice had the potential to affect 70 of 71 residents who consumed food prepared in the kitchen. Findings include: During an observation of the kitchen conducted on 11/21/2024 at 9:39 A.M. with the Culinary Nutrition Manager the following was observed in the reach-in freezer: -an open, unsealed, bag of frozen peas -an open, unsealed, bag of frozen mixed vegetables were found in the reach in freezer. During an interview on 11/21/2024 at 9:40 A.M., the Culinary Nutrition Manager indicated the bags of opened, frozen food should have been sealed after use. 3.1-21(i)(3)
Show the remaining 17 citations
- Potential for harm · Dcited before2024-11-27 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the resident and/or the resident's representative with a notice of transfer for 2 of 2 residents reviewed for hospitalization (Residents 21 & 48). 1. During an interview on 11/21/2024 at 10:22 A.M., Resident 21 indicated she had been to the hospital in the last 4 months. On 11/25/2024 at 11:25 A.M., a record review was completed for Resident 21. A Quarterly Minimum Data Set assessment (MDS), dated [DATE] indicated the resident had mild cognitive impairment. A review of Resident 21's census record indicated the resident was hospitalized on [DATE] and returned to the facility on 4/23/2024. A Nursing Progress Note, dated 4/19/2024 at 4:50 P.M., indicated after assessing the resident, the nurse called Emergency Services and the resident was transported to the hospital. During an interview on 11/25/2024 at 1:07 P.M., LPN 12 indicated the process for sending a resident to the hospital included filling out paperwork prior to the resident leaving the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-27 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 bed hold policies were provided to the resident and/or responsible parties at the time of the hospital transfer for 2 of 3 residents reviewed for hospitalization (Residents 21 & 48). Findings include: 1. During an interview on 11/21/2024 at 10:22 A.M., Resident 21 indicated she had been to the hospital in the last 4 months and did not recall receiving any paperwork prior to leaving the facility. On 11/25/2024 at 11:25 A.M., a record review was completed for Resident 21. A Quarterly Minimum Data Set assessment (MDS), dated [DATE] indicated the resident had mild cognitive impairment. A review of Resident 21's census record indicated the resident was hospitalized on [DATE] and returned to the facility on 4/23/2024. A Nursing Progress Note, dated 4/19/2024 at 4:50 P.M., indicated after assessing the resident, the nurse called Emergency Services and the resident was transported to the hospital. A Nursing Progress Note, dated 4/23/2024 at 4:30 P.M.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-27 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to provide Activities of Daily Living (ADLs) for dependent residents timely related to nail care, shaving, and turning and repositioning for 3 of 5 dependent residents who were reviewed for ADLs. (Residents 15, 38 & 14) Findings include: 1. During an observation on 11/21/2024 at 11:28 A.M., Resident 15 had long fingernails with a brown substance under them on his left hand. During an interview on 11/22/2024 at 2:15 P.M., Resident 15 indicated he had requested his nails be trimmed twice in the last week. He indicated he was unable to trim his own nails because he was blind. Resident 15 had a scab under his left eye and he indicated it was from scratching himself with his long nails. During an observation on 11/22/2024 at 2:15 P.M., Resident 15's fingernails were long and there was a brown substance under most of his nails. Resident 15's record review was completed on 11/25/2024 at 1:50 P.M. Diagnoses included, but were not limited to: Parkinson's disease, congestive heart failure, Type 2 diabetes mellitus, Major…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-27 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure 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
Based on interview and record review, the facility failed to address pharmacy recommendations timely for 1 of 5 residents reviewed for unnecessary medications. (Resident 38) Finding includes: A record review was completed on 11/25/2024 at 1:40 P.M. for Resident 38. Diagnoses included but were not limited to: generalized anxiety, radiculopathy (pinched nerve), hemiparesis/hemiplegia and repeated falls. A Significant Change Minimum Data Set (MDS) assessment, dated 11/14/2024, indicated Resident 38's cognition was intact, he had no behavior issues, had pain and took antianxiety and antidepressant medications daily. Physician Orders for Resident 38 included, but were not limited to: -11/7/2024 buspirone 10 milligrams (mg) by mouth twice a day. -11/8/2024 diazepam 5 mg by mouth twice a day -11/7/2024 trazodone 75 mg by mouth at bedtime -11/14/2024 fluoxetine 20 mg by mouth once a day -11/7/2024 gabapentin 600 mg by mouth three times a day A Pharmacy Review for Resident 38, completed on August 5, 2024 and September 10, 2024 regarding decreasing the resident's gabapentin dose were not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-27 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure infection control practices were carried out appropriately for 1 of 1 staff observed providing high contact care in an Enhanced Barrier Precautions (EBP) room for 1 of 1 residents observed in isolation (Resident 23). Finding includes: During an observation on 11/22/2024 at 9:10 A.M., Resident 23 had an Enhanced Barrier Precautions sign above her bed and an isolation cart in the room. During an observation on 11/22/2024 at 9:14 A.M., CNA 8 was observed changing the bed linens in Resident 23's room. The CNA did not have on a pair of gloves or a gown while changing the resident's bed linens. During an interview on 11/22/2024 at 9:15 A.M., CNA 8 indicated she was unaware that Resident 23 was on Enhanced Barrier Precautions. She indicated she had not seen the sign on the resident's door. During an interview on 11/22/2024 at 9:20 A.M., CNA 8 indicated, after checking with the licensed nurse, she was informed Resident 23 was on EBP due to wounds on the bottoms of both of her feet. She indicated she should have…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-10 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to notify the physician of multiple missed medication administrations for 1 of 3 residents reviewed for notification. (Resident C) Finding includes: The clinical record for Resident C was reviewed on 10/9/24 at 3:37 P.M. Diagnosis included, but were not limited to, Bipolar II disorder, borderline personality, anxiety, obsessive-compulsive disorder and chronic low back pain. Physician's Orders dated 6/10/24 to 7/2/24, indicated Resident C's prescribed orders included: Baclophen one 10 mg tablet four times a day with meals and at bedtime at 8:00 A.M., 12:00 P.M., 5:00 P.M., and 9:00 P.M., for chronic back pain, with a start date of 6/10/24 and end date of 8/12/24. Caplyta one 42 mg capsule once a day in the evenings between 7:00 P.M. and 10:00 P.M., for Bipolar II disorder, with a start date of 6/10/24 and end date of 8/12/24. Pregabalin one 100 mg capsule two times a day in the morning between 7:00 A.M. and 10:00 A.M. and again between 7:00 P.M. and 10:00 P.M., for chronic back pain with a start date of 6/10/24 and end date…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-10 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure 1 of 3 residents reviewed for medication administration, received medications as ordered by the resident's physician, (Resident C). Finding includes: The clinical record for Resident C was reviewed on 10/9/24 at 3:37 P.M. Diagnosis included Bipolar II disorder, borderline personality, anxiety, obsessive-compulsive disorder and chronic low back pain. Physician's Orders dated 6/10/24 to 7/2/24 indicated Resident C's prescribed orders included the following medications: Baclophen one 10 mg tablet four times a day with meals and at bedtime at 8:00 A.M., 12:00 P.M., 5:00 P.M., and 9:00 P.M., for chronic back pain, with a start date of 6/10/24 and end date of 8/12/24. Caplyta one 42 mg capsule once a day in the evenings between 7:00 P.M. and 10:00 P.M., for Bipolar II disorder, with a start date of 6/10/24 and end date of 8/12/24. Pregabalin one 100 mg capsule two times a day in the morning between 7:00 A.M. and 10:00 A.M. and again between 7:00 P.M. and 10:00 P.M., for chronic back pain with a start date of 6/10/24 and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-10 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure 1 of 3 residents reviewed for medication administration, had medications available from the pharmacy in a timely manor, (Resident C). Finding includes: The clinical record for Resident C was reviewed on 10/9/24 at 3:37 P.M. Diagnosis included Bipolar II disorder, borderline personality, anxiety, obsessive-compulsive disorder, and chronic low back pain. The Physician's Orders, dated 6/10/24 to 7/2/24, indicated Resident C's prescribed orders included the following: Caplyta one 42 mg capsule once a day in the evenings between 7:00 P.M. and 10:00 P.M., for Bipolar II disorder, with a start date of 6/10/24 and end date of 8/12/24. Pregabalin one 100 mg capsule two times a day in the morning between 7:00 A.M. and 10:00 A.M. and again between 7:00 P.M. and 10:00 P.M., for chronic back pain with a start date of 6/10/24 and end date 6/20/24. A review of Resident C's Medication Administration Record (MAR) from 6/10/24 to 7/2/24, indicated the resident did not receive the Caplyta medication on 6/11/24 at 6/11/24, 6/12/24,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-30 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents' environment was safe, functional, sanitary, and comfortable, related to restroom flooring not intact in 1 of 3 rooms observed. (room [ROOM NUMBER]) Findings include: On 1/29/24 at 2:42 P.M., an observation of the bathroom in room [ROOM NUMBER] was conducted. The bathroom floor was missing parts of the vinyl flooring, located on both the sides of the toilet and in front of the toilet. On 1/29/24 at 3:27 P.M., an observation of room [ROOM NUMBER]'s bathroom flooring was conducted with the Maintenance Director. He indicated the floor should not be in that condition and it looked bad. He indicated he was unaware of the flooring and indicated it was not good. He was filling in for the facility and was unaware of the floors condition. He would check to see if there had been a work order for it's repair. During an interview, on 1/29/24 at 3:32 P.M., one resident in room [ROOM NUMBER] indicated she used the bathroom daily, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-12 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to prevent verbal abuse from occurring for 2 of 3 residents reviewed for abuse. (Residents 32 and 45) Finding includes: During an interview on 12/5/2023 at 9:38 A.M., Resident 32 indicated that the facility was allowing Resident 45 to engage in verbal violence. She indicated the last occurrence was 3 days ago on 12/2/2023. Resident 45 called her a pig and other names while in the dining room at an adjacent table when the incident occurred. Resident 32 indicated the facility allowed the verbally aggressive resident to sit at the table next to her. She shouldn't have to feel afraid, and feels bad about Resident 45 laughing at her. Resident 32 indicated the guy in the office won't do anything about the issue. During an interview on 12/6/2023 at 9:45 A.M., Resident 53 indicated that two ladies got into an argument in the dining room, and he intervened verbally. Residents 32 and 45 were involved. He indicated these verbal issues happened frequently between the two residents and no staff intervened in this incident until he became…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-12 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to report an allegation of verbal abuse timely for 2 of 3 residents reviewed for abuse. (Residents 32 and 45) Finding includes: Cross Reference F600. During an interview on 12/5/2023 at 9:38 A.M., Resident 32 indicated that the facility was allowing Resident 45 to engage in verbal violence. She indicated the last occurrence was about 3 days ago. Resident 45 called her a pig and other names while in the dining room at an adjacent table when the incident occurred. Resident 32 indicated the facility allowed the verbally aggressive resident to sit at the table next to her. She shouldn't have to feel afraid, and feels bad about Resident 45 laughing at her. Resident 32 indicated the guy in the office won't do anything about the issue. During an interview on 12/6/2023 at 9:45 A.M., Resident 53 indicated two ladies got into an argument in the dining room, and he intervened verbally. He indicated Residents 32 and 45 were involved. He indicated these verbal issues happened frequently between the two residents. He indicated no staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-12 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 thoroughly investigate an allegation of resident to resident verbal abuse for 2 of 3 residents reviewed for abuse. (Residents 32 and 45) Finding includes: Cross reference F600. During an interview on 12/5/2023 at 9:38 A.M., Resident 32 indicated that the facility was allowing Resident 45 to engage in verbal violence. She indicated the last occurrence was 3 days ago on 12/2/2023. Resident 45 called her a pig and other names while in the dining room at an adjacent table when the incident occurred. Resident 32 indicated the facility allowed the verbally aggressive resident to sit at the table next to her. She shouldn't have to feel afraid, and feels bad about Resident 45 laughing at her. Resident 32 indicated the guy in the office won't do anything about the issue. On 12/6/2023 at 9:45 A.M., Resident 53 indicated two ladies got into an argument in the dining room, and he intervened verbally. He indicated Residents 32 and 45 were involved. He 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.
- Potential for harm · D2023-12-12 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 care plan regarding activities was individualized and based on resident assessment for 1 of 18 residents whose care plans were reviewed. (Resident 21) Finding includes: The clinical record for Resident 21 was reviewed on 12/06/2023 at 3:45 P.M. The resident was admitted to the facility with diagnoses including, but not limited to: hemiplegia/hemiparesis following a cerebral infarction, encephalopathy, severe protein calorie malnutrition, dysphagia, aphasia, major depressive disorder, recurrent, anxiety disorder, chronic pain, gastrostomy, insomnia, adult failure to thrive, mitral valve insufficiency, emphysema and kidney stones. On 12/06/2023 at 11:15 A.M., Resident 21 was observed lying in bed with the head of the bed slightly elevated. Resident 21 indicated he just lays there and does nothing. When asked what he liked to do before he entered the facility, he indicated he never liked to be around a lot of people, but enjoyed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a dependent resident was offered a shave, oral care daily and hair washed during complete bed bath for 1 of 2 residents reviewed for ADLs (activities of daily living). (Resident 232) Finding includes: A record review was completed for Resident 232 on 12/7/2023 at 1:35 P.M. Diagnoses included, but were not limited to: metabolic encephalopathy, quadriplegia, chronic kidney disease, type 2 diabetes mellitus, and central cord syndrome at unspecified level of cervical spinal cord. An admission Minimum Data Set (MDS) assessment, dated 12/4/2023, indicated he was dependent for all activities of daily living and had limited range of motion impairment to upper and lower extremities. During an observation and interview on 12/6/2023 at 11:07 A.M., Resident 232's hair was greasy in appearance and he was unshaven. He indicated he had only been assisted with shaving one time, had only a few bed baths, went 6-7 days without his teeth brushed, and his hair not washed. He shaved at home every day and brushed his teeth…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-12 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
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 interviews, the facility failed to ensure an individualized activity program was implemented for 2 of 2 residents reviewed for activities. (Residents 21 and 232) Findings include: 1. The clinical record for Resident 21 was reviewed on 12/6/23 at 3:45 P.M. Resident 21 was admitted to the facility with diagnoses including, but not limited to: hemiplegia/hemiparesis following a cerebral infarction, encephalopathy, severe protein calorie malnutrition, dysphagia, aphasia, major depressive disorder, recurrent, anxiety disorder, chronic pain, gastrostomy, insomnia, adult failure to thrive, mistral valve insufficiency, emphysema and kidney stones. On 12/6/2023 at 11:15 A.M., Resident 21 was observed lying in bed with the head of the bed slightly elevated. He indicated he just lays there and does nothing. When asked what he liked to do before he entered the facility, he indicated he never liked to be around a lot of people, enjoyed fishing at the river and being outside. He never…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-12 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to follow physician's orders related to administration of insulin for 1 of 2 residents reviewed for insulin use. (Resident 53) Finding includes: During an interview with Resident 53 on 12/6/2023 at 9:59 A.M., he indicated he received insulin injections on a daily basis. A record review was completed on 12/7/2023 at 9:17 A.M. Diagnoses included, but were not limited to: diabetes mellitus type 2 and major depressive disorder. A Quarterly Minimum Data Set (MDS) assessment indicated Resident 53 received insulin. Physician's Orders on the current POS (Physician's Order Summary) included the following: - Lispro 100 units/milliliter, give 15 units subcutaneously three times a day, and hold for a blood sugar reading of less than 110, dated 3/6/2023. - Lantus Solostar 100 unit/milliliter, give 25 units at bedtime, and hold for a blood sugar reading less than 110, dated 3/7/2023. - Accucheck (glucometer device to monitor blood sugar levels) as needed for signs and symptoms of hypo/hyperglycemia and notify the medical doctor if the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-12 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to ensure the medication regimen for 1 of 5 residents reviewed for medications was free from unnecessary medications related to the lack of laboratory levels. (Resident 22) Finding includes: The clinical record for Resident 22 was reviewed, on 12/8/2023 at 2:28 P.M., with diagnosis, including but not limited to: hyperlipidemia and hypothyroidism The current Physician's Orders for medications for Resident 22 included the following: Levothyroxine (a medication to address thyroid issues) and Lipitor (a medication to address elevated cholesterol levels). The most recent laboratory blood levels for a TSH (thyroid stimulating hormone) and Lipid panel (blood test to address various cholesterol levels in the body) were completed in 2021, over two years ago. During an interview with the DON (Director of Nursing), on 12/11/2023 at 11:17 A.M., she indicated the physician only ordered labs when he felt they were pertinent or when something was going 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to AMERICAN SENIOR COMMUNITIES — 90 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.9 | -1.9 vs chain |
| Health inspection | 2 of 5 | 3.4 | -1.4 vs chain |
| Staffing | 1 of 5 | 2.3 | -1.3 vs chain |
| Quality measures | 5 of 5 | 4.7 | +0.3 vs chain |
The other 89 homes this chain runs (chain average 3.9★, per CMS)
Showing 40 of 89; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| THE HEALTH AND HOSPITAL CORPORATION OF MARION COUNTY | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 10/01/2006 |
| OHI ASSET (IN) ELKHART, LLC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | since 08/31/2012 |
| CHIES, STEVEN | Individual | MANAGING CONTROL - GOVERNING BODY | since 03/17/2016 |
| JACKSON, BLAKE | Individual | MANAGING CONTROL - GOVERNING BODY | since 10/01/2006 |
| JACKSON, ETHAN | Individual | MANAGING CONTROL - GOVERNING BODY | since 10/01/2006 |
| JACKSON, MARK | Individual | MANAGING CONTROL - GOVERNING BODY | since 10/01/2006 |
| JACKSON, MICHAEL | Individual | MANAGING CONTROL - GOVERNING BODY | since 05/14/2024 |
| JACKSON, WESSLEY | Individual | MANAGING CONTROL - GOVERNING BODY | since 10/01/2006 |
| JUSTICE, DAVID | Individual | MANAGING CONTROL - GOVERNING BODY | since 10/01/2006 |
| KELSEY, DONNA | Individual | MANAGING CONTROL - GOVERNING BODY | since 07/18/2024 |
| STITLE, STEPHEN | Individual | MANAGING CONTROL - GOVERNING BODY | since 03/16/2016 |
| WRIGHT, THERESSA | Individual | MANAGING CONTROL - GOVERNING BODY | since 05/21/2021 |
| DOUCET, KELLY | Individual | CORPORATE DIRECTOR | since 02/03/2025 |
| DRUMMER, CARL | Individual | CORPORATE DIRECTOR | since 01/01/2017 |
| FISCH, GARY | Individual | CORPORATE DIRECTOR | since 01/01/2025 |
| HANIFY, THOMAS | Individual | CORPORATE DIRECTOR | since 01/01/2022 |
| HORN, BRENDA | Individual | CORPORATE DIRECTOR | since 09/20/2023 |
| LAZARD, ROBERT | Individual | CORPORATE DIRECTOR | since 01/29/2021 |
| O'BRIEN, MICHAEL | Individual | CORPORATE DIRECTOR | since 02/03/2025 |
| BABCOCK, PAUL | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 09/30/2020 |
| CAINE, VIRGINIA | Individual | CORPORATE OFFICER | since 01/10/1994 |
| GODDARD, NICHOLE | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 07/11/2022 |
| HARRIS, LISA | Individual | CORPORATE OFFICER | since 12/22/2003 |
| SIMPSON, JAMES | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 08/06/2023 |
| AMERICAN SENIOR COMMUNITIES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/19/2026 |
| DICE, MARK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2023 |
| SHANE, ANDREW | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2023 |
| SIDDIQI, ISRAR | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/01/2019 |
| SMITH, KYLE | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 06/01/2026 |
| TOMASI, BRYCE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/07/2025 |
| VAN CAMP, STEVEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2023 |
CMS files one row per role, so the 42 rows in the source record cover these 31 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.
About 74% 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 $775K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Indiana Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 155695. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-24, 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.