Richland Bean Blossom Health Care Center
5911 State Road 46, Ellettsville, IN 47429 · Non profit - Corporation · 74 certified beds · (812) 876-6400 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
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0602), cited Feb 2024
- it has a citation for mishandling residents’ money or property (F0565)
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (76%) 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 | 3 of 5 |
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 | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 7.4% | 11.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 10.7% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.1% | 0.4% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.8% | 1.1% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 5.1% | 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 | 7.2% | 3.9% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 11.2% | 11.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 24.1% | 23.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 84.7% | 95.4% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 3.6% | 3.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 17.8% | 23.3% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 25.0% | 13.6% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 4.8% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 67.7% | 79.0% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 29.4% | 22.2% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 14.6% | 10.8% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.04 | 1.61 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.86 | 1.44 | 1.80 | 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.
50.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 63.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 30 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.
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 | 50.4%CMS range 33.6–60.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.8%CMS range 7.9–16.8 | 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 | 63.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 63.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 63.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 46.9% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 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 | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.8%CMS range 3.4–12.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.77 | 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 74 beds and averages 55.2 residents a day — about 75% occupied, or roughly 19 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.34 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.41 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.26 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 2.82 hrs/resident/day on weekends vs 3.55 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.44 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 76% is well above the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.
- Potential for harm · F2026-04-10 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to submit accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (Centers for Medicare and Medicaid) for 22 days out of a quarter (Fiscal Year Quarter 1). Findings include: On 4/6/26 at 10:45 a.m., the facility's Certification and Survey Provider Enhanced Reports (CASPER) was reviewed.The CASPER report indicated the following:- The facility failed to have Licensed Nursing Coverage 24 Hours/Day on 10/4/25; 10/18/25; 10/19/25; 10/25/25; 10/26/25; 11/1/25; 11/2/25; 11/8/25; 11/9/25; 11/15/25; 11/16/25; 11/23/25; 11/29/25; 11/30/25; 12/6/25; 12/7/25; 12/13/25; 12/14/25; 12/20/25; 12/21/25; 12/27/25; 12/28/25.- The facility had low weekend staffing.- The facility had a 1 start staffing rating. A review of the staffing sheets from the quarter indicated the facility was fully staffed and had licensed nurse on all of the days listed above. During an interview on 4/9/26 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-04-10 · tag F0628 — patternProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure the written notifications required for a transfer/discharge and bed hold policy was provided to the resident and/or the resident representative for 4 of 4 residents reviewed for discharge and hospitalization. (Resident 2, Resident 7, Resident 27 and Resident 53).Findings include: 1. On 4/7/26 at 9:38 a.m., Resident 27's clinical record was reviewed. The diagnoses included, but were not limited to, generalized anxiety disorder (a mental health condition characterized by excessive, uncontrollable worry about everyday things, lasting at least six months), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (loss of memory, language, problem-solving and other thinking abilities). Resident 27's progress notes indicated the following: - On 12/9/25 at 10:35 p.m., the resident complained chest pain, lower back pain, and shortness of breath. 911 was called and the resident was transported to the hospital. - On 12/15/25, time unknown, the resident returned…
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 · D2026-04-10 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to ensure staff electronically transmitted the MDS (Minimum Data Set) data to the CMS (Centers for Medicare and Medicaid) System within 14 days of completion for 1 of 24 residents reviewed for transmittal data. (Resident 36)Findings include:On 4/9/26 at 10:06 a.m., Resident 36's clinical record was reviewed. An Annual MDS assessment, dated 2/23/26, indicated it was over 120 days past due for submission to CMS.During an interview on 4/10/26 at 11:22 a.m., the MDS coordinator indicated she had 2 care area assessments left to complete on the annual MDS assessment, she had just completed them and had submitted the MDS to CMS.During an interview on 4/10/26 at 12:05 p.m., the Administrator indicated the facility did not have a policy in regard to MDS transmissions.
- Potential for harm · Dcited before2026-04-10 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 the MDS (Minimum Data Set) assessment accurately reflected a resident's status for 2 of 24 residents reviewed for MDS accuracy. (Resident 4, Resident 27)Findings include: 1. On 4/9/26 at 10:07 a.m., Resident 4's clinical record was reviewed. The diagnoses included, but were not limited to, bipolar disorder and anxiety. An Annual MDS assessment, dated 3/11/26, indicated the resident was not currently considered by the state Level II PASARR (Preadmission Screening and Resident Review) process to have a serious mental illness and/or intellectual disability or related condition. A Level II PASARR was completed on March 31, 2023. During an interview on 4/10/26 at 11:10 a.m., the MDS coordinator indicated she corrected the resident's MDS assessment to accurately reflect the PASARR Level II information. During an interview on 4/10/26 at 12:05 p.m., the Administrator indicated the facility did not have a policy in regard to MDS assessment coding, but followed the RAI (Resident Assessment Instrument) manual. 2. On 4/9/26 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-09 · 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 narcotic pain medication was reconciled when it was delivered from the pharmacy. (Resident B) Findings include:During an interview on 12/9/25 at 8:23 a.m., the Administrator indicated, on 9/23/25, Licensed Practical Nurse (LPN) 1 reported that she was not able to locate Resident B's oxycodone-acetaminophen (narcotic pain medication) 7.5 milligrams (mg)-325 mg. When LPN 1 called the pharmacy, she was told that 30 oxycodone-acetaminophen 7.5-325 mg tablets had been delivered for Resident B on 9/21/25. LPN 2 had signed the delivery slip for the controlled medications that night but did not follow the proper procedure for reconciling the controlled medications that had been delivered with what was listed on the delivery slip before she signed for them. LPN 2 did not reconcile the narcotic medications she placed in the locked drawer on the medication cart with the narcotic disposition record. The oxycodone-acetaminophen 7.5-325mg that was delivered, on 9/21/25, was never located. LPN 2's employment had been terminated…
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 · E2025-05-09 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
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 promptly respond to grievances from the resident council meetings for 5 of 5 residents interviewed. (Resident 11, Resident 31, Resident 55, Resident 45, Resident 41) Findings include: During a resident council meeting on 5/7/25 at 10:01 a.m., Resident 11, Resident 31, Resident 55, Resident 45, and Resident 41, indicated if a meal included a wet item, such as corn, their bread was often soggy and unappetizing. The resident's indicated they had told staff this was a problem multiple times and it was an ongoing problem. A review of the resident council meeting minutes indicated the following: - On 12/26/24, the residents indicated they would like separate dishware for liquid type foods, such as, cottage cheese, fruit, baked beans, etc. - On 2/27/25, the residents discussed the need of bowls for liquid foods. - On 3/27/25, the residents indicated when liquid foods were on the plate with regular food, the sandwiches, or breads would get soggy. On 5/7/25 at 12:10 p.m., a test tray was obtained from the 300 hall…
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 · E2025-05-09 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
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 implement an ongoing resident centered activities program for 13 of 13 residents who resided on the secure dementia unit. Findings include: On the following dates and times, residents of the secured dementia unit were observed walking in the hallway, and sitting in the dining area and common area with no structured activities taking place: - On 5/5/25 from 11:00 a.m. to 12:30 p.m. and from 2:00 p.m. to 3:05 p.m. - On 5/6/25 from 9:40 a.m. to 12:15 p.m. and from 1:40 p.m. to 2:55 p.m. - On 5/7/25 from 9:45 a.m. to 11:55 a.m. and from 1:20 p.m. to 3:00 p.m. - On 5/8/25 from 9:30 a.m. to 11:05 a.m. No activities schedule was observed posted or located on the closed dementia unit. During confidential interviews during the course of the survey, they indicated there had been no activities calendar or schedule posted on the unit for several months, and no scheduled activities had taken place for several months, including the survey period. On occasion, an activities assistant would come to the unit to do unscheduled…
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 · E2025-05-09 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff on the secured dementia unit for 13 of 13 residents who resided on the secure dementia unit (Resident 13, Resident 15, Resident 19, Resident 23, Resident 34, Resident 53, Resident 32, Resident 14, Resident 52, Resident 8, Resident 54, Resident 208, and Resident 48). Findings include: On 5/6/25 at 2:10 p.m., LPN 1 was observed attending to Resident 34 who was ambulating in an unsteady manner in the hallway. LPN 1 observed Resident 52 ambulating in an unsteady manner farther down the hallway and instructed Resident 34 to hold to the hallway railing in order to attend to Resident 52. During this time, QMA 1 was assisting a resident in a resident bathroom. CNA 1 was in the shower room with another resident. LPN 1 guided Resident 52 to a chair in the common area and returned to assist Resident 34. On 5/7/25 at 1:30 p.m. LPN 1 was observed assisting Resident 34 to a chair in the common area. CNA 1 was assisting a resident in a resident room. Resident 34 was resistant to sitting 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 · E2025-05-09 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 staff served food that had a palatable texture and appearance for 1 of 1 test trays observed. (Resident 11, Resident 31, Resident 55, Resident 45, Resident 41, Resident 17) Findings include: During a resident council meeting on 5/7/25 at 10:01 a.m., Resident 11, Resident 31, Resident 55, Resident 45, and Resident 41, indicated if a meal included a wet item, such as corn, their bread was often soggy and unappetizing. They indicated they had told staff this was a problem multiple times and it was an ongoing problem. On 5/7/25 at 12:10 p.m., a test tray was obtained from the 300 hall cart. The meal included a hamburger on a bun, fried onion rings, and whole kernel corn on a flat plate. The corn was beneath the bun and a few onion rings were on top of the corn. The bottom of the hamburger bun and the onion rings placed on top of the corn were soggy. During an interview on 5/7/25 at 12:15 p.m., the Administrator did not deny the hamburger bun was soggy. During an interview on 5/7/25 at 12:20 p.m., Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-09 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure residents and/or their representative were provided informed consent prior to initiating an antipsychotic medication for 1 of 6 residents reviewed for unnecessary medications. (Resident 13) Findings include: On 5/6/25 at 2:09 p.m., Resident 13's clinical record was reviewed. The diagnoses included, but were not limited to, myotonic muscular dystrophy (a genetic disorder characterized by progressive muscle weakness and difficulty relaxing muscles after use), psychosis (significant loss of contact with reality, often characterized by hallucinations and delusions), and senile degeneration of the brain (a decline in cognitive function). A review of physician's orders indicated the following: On 4/29/25, an order for Olanzapine (an antipsychotic medication) 2.5 mg (milligrams) once daily was prescribed for a diagnosis of psychosis. A review of Resident 13's progress notes indicated the following: On 4/29/25, the resident informed staff that she saw an accident take place that had multiple casualties. The resident was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 15 citations
- Potential for harm · D2025-05-09 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
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 resident's care planning conferences were completed for 1 of 1 residents reviewed for care planning. (Resident 41) Finding includes: During an interview on 5/6/25 at 9:48 a.m., Resident 41 indicated the staff did not involve him or his family in care conferences, and he could not remember the staff ever involving him with the development of his care plan. On 5/6/25 at 11:10 a.m., the resident's clinical record was reviewed. The diagnoses included, but were not limited to hemiplegia (complete paralysis on one side) and hemiparesis (partial weakness on one side of the body) following a cerebral infarction (a condition where brain tissue dies due to a lack of blood flow) affecting left non-dominant side, need for assistance with personal care, dysphagia following cerebrovascular disease, and cerebral infarction without residual deficits. A Quarterly Minimum Data Set (MDS) assessment, dated 2/19/25, indicated the resident had moderately impaired cognition. A review of the resident's clinical record indicated his last…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-09 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
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 reasonable accommodation of needs for 1 of 5 residents interviewed during the resident council meeting. Call lights were not within reach. (Resident 55) Findings include: During a resident council meeting on 5/7/25 at 10:01 a.m., Resident 55 indicated she did not have access to her call light. Resident 55 indicated the staff had recently deep-cleaned their room and they did not have use of their call lights for 24 hours. Resident 55 insisted she still did not have access to her call light because it was under a stack of plastic totes in their room. On 5/7/25 at 10:45 a.m., Resident 55's call light was observed on the floor, under a plastic storage container. She would not have had prompt access to call for help. On 5/7/25 at 11:00 a.m., Resident 55's clinical record was reviewed. The diagnoses included, but were not limited to, unsteadiness on feet, difficulty in walking, need for assistance with personal care, and glaucoma. The Quarterly Minimum Data Set (MDS) assessment, dated 1/16/25, indicated 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 before2025-05-09 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident representative was notified of a change in condition and treatments for 1 of 1 resident's reviewed for death. (Resident 57) Findings include: On [DATE] at 2:31 p.m., Resident 57's closed clinical record was reviewed. The diagnoses included, but were not limited to, dementia, muscle weakness, need for assistance with personal care, and stage 3 chronic kidney disease. A review of the resident's progress notes indicated the following: - On [DATE] at 10:22 p.m., the resident was ordered 2 liters (2 bags) of sodium chloride solutions for dehydration. His son and wife were notified. The note was recorded as a late entry on [DATE] at 10:24 p.m. - On [DATE] at 3:35 a.m., the sodium chloride (0.9% NaCl) solutions were completed via hypodermoclysis (the subcutaneous infusion of fluids, a hydration technique suitable for mildly to moderately dehydrated adult patients). - On [DATE] at 7:56 a.m., the resident had fatigue, a change in mental…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-09 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure an accurate MDS (Minimum Data Set) assessment for 2 of 2 residents reviewed for resident assessment. (Resident 31, Resident 11) Finding includes: 1. On 5/8/25 at 2:52 p.m., Resident 31's clinical record was reviewed. The diagnoses included, but were not limited to, bipolar disorder (a mental health condition causes extreme mood swings), dementia (a group of diseases that affect your thinking, memory, reasoning, personality, mood and behavior), and mood disorder (a mental health condition characterized by significant and persistent changes in mood). A review of the notice of PASARR (Preadmission Screening and Resident Review) Level II Outcome, dated 5/22/23, indicated, Final Determination By: Determination Date: 5/22/23, Level II Outcome: Long Term Approval without Specialized Services. The Annual MDS assessment, dated 6/27/24, did not indicate resident was a PASARR level II. During an interview with the Clinical Reimbursement Director on 5/9/25 at 12:15 p.m., she indicated section A1500 on MDS assessment, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a resident received the necessary interventions to prevent the development of a pressure ulcers for 1 of 2 residents reviewed for pressure ulcers. A resident developed a Stage 3 pressure ulcer. (Resident 38) Findings include: During an observation on 5/6/25 at 2:56 p.m., Resident 38 was observed to be resting in her bed on her back and her heels were on the bed. Her heels were not observed to be floated on pillows. During an observation on 5/7/25 at 9:43 a.m., Resident 38 was observed to be resting in the bed on her back and her heels were on the bed. Her heels were not observed to be floated on pillows. During an observation on 5/7/25 at 1:57 p.m., Resident 38 was observed to be resting in the bed on her back and her heels were on the bed. Her heels were not observed to be floated on pillows. During an observation on 5/8/25 at 9:30 a.m., Resident 38 was observed to be resting in the bed on her back and her heels were on the bed. Her heels were not observed to be floated on pillows. During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-09 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide 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
Based on observation, interview, and record review, the facility failed to ensure a resident with limited range of motion received services to prevent further decline for 1 of 2 residents reviewed for mobility.(Resident 41) Findings include: During an interview on 5/6/25 at 9:55 a.m., Resident 41 indicated his left hand did not open and he would like to try a splint to see if that improved his left hands function and mobility. His left hand was observed to not fully open and did not have a splint in place. On 5/6/25 at 2:19 p.m., Resident 41 was observed in his room without a splint on his left hand. On 5/7/25 at 1:57 p.m., Resident 41 was observed in his bed without a splint on his left hand. He indicated staff did not do any range of motion exercises with him. On 5/6/25 at 11:10 a.m., Resident 41's clinical record was reviewed. The diagnoses included, but were not limited to hemiplegia (complete paralysis on one side) and hemiparesis (partial weakness on one side of the body) following a cerebral infarction (a condition where brain tissue dies due to a lack of blood flow)…
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 · D2025-05-09 · 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 implement infection control practices for 1 of 11 residents observed for care. Gloves were not changed, hands were not washed, and Enhanced Barrier Precautions were not implemented. (Resident 38) Findings include: During an observation of a pressure ulcer dressing change on 5/7/25 at 10:46 a.m., the Assistant Director of Nursing (ADON) went into Resident 38's room with treatment supplies to change Resident 38's pressure ulcer dressing. The ADON placed the treatment supplies on Resident 38's bed. CNA 4 performed incontinent care on Resident 38. CNA 4 removed her soiled gloves. She was observed to put on a new pair of gloves. CNA 4 was not observed to wash her hands or apply hand sanitizer prior to putting on the new gloves. The ADON removed the soiled dressing from Resident 38's coccyx. The ADON did not change her gloves after removing the old dressing and placing the new dressing on. The ADON picked up the treatment supplies and placed them back in the treatment cart. The ADON and CNA 4 were not observed 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 · Dcited before2024-09-24 · 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 accurate acquiring and accounting of controlled substances for 1 of 3 residents reviewed for pharmacy services. (Resident E) Findings include: Resident E's clinical record was reviewed on 9/24/24 at 11:00 a.m. The diagnoses included, but were not limited to, end stage renal disease and pain. Physician Orders, dated 8/24/24 through 9/24/24, indicated Resident E's medications included, but were not limited to, hydrocodone-acetaminophen (a pain medication) Schedule II (drugs with high potential for abuse) tablet 7.5-325 mg (milligram) one every six hours as needed for pain. The medication start date was 4/17/24. The pharmacy document titled, Packing Slip was reviewed on 9/25/24 at 11:45 a.m., for Resident E and indicated 60 hydrocodone-acetaminophen tablets 7.5-325 mg were delivered to the facility on 8/28/24. The medication was received and signed for by LPN 1. The facility document titled, Controlled Substance Acceptance Log was reviewed on 9/25/24 at 11:50 a.m., for Resident E. The document was observed to be blank…
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 · D2024-07-12 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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 the resident's representative was informed of the baseline care plan for 1 of 1 residents reviewed for mood and behavior. (Resident 56) Finding include: On 7/11/24 at 10:15 a.m., Resident 56' clinical record was reviewed. The diagnoses included, but were not limited to, Alzheimer's disease, anxiety, and insomnia. His admission date was 6/6/24. Resident 56's Interim 48 hour baseline care plan was started on 6/6/24. The clinical record lacked documentation of the resident's representative being informed of the baseline care plan. During an interview on 7/12/24 at 10:24 a.m., the Social Service Designee (SSD) indicated when a new admission was admitted , the facility would have a 72 hour care plan with the family to go over the baseline care plan. During an interview on 7/12/24 at 11:44 a.m., the SSD indicated the clinical record lacked documentation of the 72 hour care plan meeting with family. On 7/12/24 at 11:59 a.m., the Regional Operational Support provided the the facility policy, Resident/Family Participation -…
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 · D2024-07-12 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
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 staff completed a discharge summary that included a recapitulation of the resident's stay, a final summary of the resident's status, and a post-discharge plan of care developed with the participation of the resident for 1 of 1 resident reviewed for discharge. (Resident 58) Findings include: On 7/11/24 at 11:34 a.m., Resident 58's clinical record was reviewed. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, bipolar II disorder, major depressive disorder, anxiety, abnormalities of gait and awareness, cognitive communication deficit, sleep disorder, dysphagia (difficulty swallowing foods or liquids), and need for assistance with personal care. A 4/17/24 discharge Minimum Data Set (MDS) assessment indicated the resident required supervision for self care and ambulation. A review of the resident's progress notes indicated the following: - On 4/10/24 the resident notified the social worker she was going to discharge to Missouri on 4/17/24 at 5:00 p.m. She would go home without home…
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 · D2024-07-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide respiratory care for 1 of 1 residents reviewed. Oxygen tubing was not changed. (Resident 18) Findings include: On 7/9/24 at 12:35 p.m., Resident 18 was observed lying in bed with oxygen (O2) being administered via nasal cannula (NC) at 2 liters (L). The nasal cannula was dated 6/8/24. On 7/10/24 10:40 a.m., Resident 18 was observed lying in bed with O2 being administered via NC at 2 L. The nasal cannula was dated 6/8/24. On 7/10/24 1:18 p.m., Resident 18 was observed sitting in wheel chair with portable oxygen being administered at 2 L via NC, the NC tubing was dated 4/28 (no year indicated). On 7/10/24 2:43 p.m., Resident 18 was observed lying in bed without oxygen on. She indicated she knew she was supposed to wear it at all times but she took it off at times. The NC was lying on the bed next to resident, which was dated for 6/8/24. Resident 18 picked up the tubing and placed in her nose at that time. The NC observed on portable oxygen was dated 4/28. On 7/11/24 9:36 a.m., Resident 18 was observed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-12 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 — the official record, unedited, may be distressing
Based on observation, interview, and record review, the facility failed to label a vial (glass container for holding liquid medication) with the opened date for 1 of 2 medication rooms observed. Findings include: On 7/12/24 at 9:20 a.m., the refrigerator in the medication room was observed to have vial of Tubersol (a solution to aid in diagnosis of tuberculosis infection) in a box. The vial and the box lacked an opened date. The Director of Nursing (DON) could not find an opened date, and all opened vials should have an opened date on them. On 7/12/24 at 9:45 a.m., the DON provided the facility's policy, Determining Expiration Dates, undated and indicated it was the policy being used by the facility. A review of the policy indicated .Tubersol/Aplisol .30 days once opened (Refrigerated) . 3.1-25(j)
- Potential for harm · Dcited before2024-02-08 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure the physician was notified of a change in condition for 1 of 3 residents reviewed. Staff did not notify the physician prior to implementing new orders. (Resident C, RN 1) Finding includes: On 2/8/24 at 10:00 a.m., Resident C's clinical record was reviewed. The diagnoses included, but were not limited to, repeated falls, age related physical debility, and mild cognitive impairment. A Progress Note, dated 2/3/24 at 8:51 a.m., written by RN 1, indicated Resident C complained of constipation and Miralax (stool softener) and Colace (stool softener) were added to her physicians orders as needed medications. The clinical record lacked documentation the physician was notified regarding the new concern of constipation for Resident C. The Physician's Orders, included, but were not limited to: Docusate sodium (Colace), 100 mg (milligrams), give one tablet daily as needed for constipation, initiated on 2/3/24. Miralax powder, give 17 grams one time daily as needed for constipation, initiated on 2/3/24. On 2/8/24 at 9:55 a.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 · D2024-02-08 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to protect a resident right to be free from misappropriation of property for 1 of 1 residents reviewed. A controlled substance was unaccounted for and could not be located. (Resident B) Finding includes: On 2/8/24 at 11:35 a.m., a facility reportable incident was reviewed. The reportable incident indicated that a resident's (Resident B) narcotic card and sign out sheet were both missing and that an investigation was initiated. The clinical record for Resident B was reviewed on 2/8/24 at 11:00 a.m. The diagnoses included, but were not limited to, unspecified pain, unspecified osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), and unspecified neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet). The Significant Change in Status MDS (Minimum Data Set) assessment, dated for 10/31/23, indicated that Resident B had severe cognitive impairment. A Physician's order, initiated 3/6/23 and discontinued on 1/4/23, indicated oxycodone (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.
- No harm found · C2025-05-09 · tag F0574 — widespreadThe resident has the right to receive notices in a format and a language he or she understands.
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 residents were informed of the state and local advocacy organization and contact information for filing complaints. This had to potential to affect 58 out of 58 residents residing in the facility. Findings include: During a resident council meeting on 5/7/25 at 10:36 a.m., residents indicated they did not know where the State Survey Agency (SSA) or the State Long-Term Care Ombudsman information was posted. They further indicated they did not know how to file a complaint with the State Survey Agency. During an observation on 5/7/25 at 10:49 a.m., the local advocacy information was observed posted up by the front entrance approximately 4 and one half feet from the floor. The posting was located amongst other papers and was not easily identifiable nor within eyesight of a wheelchair bound resident. On 5/7/25 at 3:20 p.m., the resident council meeting minutes were reviewed. The resident council meeting minutes did not indicate the SSA or ombudsman posting information was discussed during meetings. During…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PUTNAM COUNTY HOSPITAL | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 06/01/2015 |
| BRAY, ARNOLD | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 09/01/2012 |
| FRY, JANICE | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 09/01/2012 |
| HEADLEY, MATTHEW | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 09/01/2012 |
| LANDRY, KEITH | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 09/01/2020 |
| LEWIS, KATRINA | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 12/21/2022 |
| SILLERY, DEBRA | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/03/2026 |
| UNDERWOOD, WENDELL | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 05/20/2024 |
| WEATHERFORD, DENNIS | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | — | since 09/18/2012 |
| WOOD, MARK | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 08/05/2024 |
| HHSS MANAGEMENT, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2020 |
| RICHLAND BEAN BLOSSOM LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/19/2025 |
| DAVIS, TONIA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/14/2025 |
| MARTIN, THOMAS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2021 |
| LOUDERMILK, CHRISTOPHER | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 09/19/2025 |
| HOOSIER CARE PROPERTIES INC | Organization | ADP OF THE SNF | — | since 06/01/2015 |
| HOOSIER WEST LEASING COMPANY LLC | Organization | ADP OF THE SNF | — | since 11/06/2012 |
| RBB FACILITIES COMPANY LLC | Organization | ADP OF THE SNF | — | since 11/06/2012 |
CMS files one row per role, so the 24 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted.
6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $613K 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 155523. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-10, 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.