Heritage Center
1201 W Buena Vista Rd, Evansville, IN 47710 · Government - County · 172 certified beds · (812) 429-0700 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- about 29% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 23.5% | 11.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 8.0% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.2% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.9% | 1.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 10.8% | 25.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 5.5% | 3.9% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 21.4% | 11.9% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 30.6% | 23.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 92.4% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.0% | 3.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 32.6% | 23.3% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.3% | 13.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.3% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 83.5% | 79.0% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 26.3% | 22.2% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 10.5% | 10.8% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.39 | 1.61 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.69 | 1.44 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
61.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 327 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 64.2% 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 190 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.28 therapist hours per resident per day in 2026Q1 — more than 43% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 18% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 61.1%CMS range 57.9–65.0 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.0%CMS range 7.2–13.1 | 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 | 64.2% | 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 | 64.7% | 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 | 41.6% | 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 | 51.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.2% | 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 | 5.2%CMS range 2.6–8.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.56 | 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 172 beds and averages 126.8 residents a day — about 74% occupied, or roughly 45 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 4.00 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.43 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.76 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.52 hrs/resident/day on weekends vs 4.20 on weekdays — 16% thinner on weekends. RN hours go from 0.48 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
31 citations, most serious first. The 12 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · Gcited before2022-07-05 · 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 residents admitted without pressure ulcers were provided effective interventions to prevent the development of an unstageable pressure ulcer on the spine for 1 of 5 residents who met the criteria for review of pressure ulcers. (Resident B) Finding includes: During an observation on 6/27/22 at 10:25 A.M., Resident B was observed laying in bed on Resident's back with blankets covering Resident B's shoulders. During an observation on 6/28/22 at 8:24 A.M., Resident B was observed laying in bed on Resident's back with blankets covering Resident B's shoulders. During an observation on 6/30/22 at 11:34 A.M., Resident B's dressing was changed. Resident B had a small white area on Resident B's spine on the lower portion of the back. On 6/28/22 at 8:58 A.M., Resident B's clinical record was reviewed. Current diagnosis included, but were not limited to, muscle weakness, anemia, heart failure, hypertension, pneumonia, hyponatremia, and respiratory failure. The most recent quarterly MDS (minimum data set)…
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.
- Actual harm · Gcited before2022-07-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent falls for 2 of 5 residents reviewed for falls, both residents received fractured femurs from their falls. Resident 41 had five additional falls after the fracture one resulting in a major injury. (Resident 41, Resident 76) Findings include: 1. On 7/1/22 at 10:51 A.M., Resident 41's clinical record was reviewed. Diagnoses included, but were not limited to, nontraumatic brain dysfunction and dementia. The most recent admission MDS (minimum data set) Assessment, dated 4/7/22, indicated Resident 41 had a severe cognitive impairment, and required assistance of 1 (one) staff for all ADLs (activities of daily living). The MDS indicated Resident 41 had not fallen in the previous 6 months prior to admission, and had fallen 1 (one) time since admission to the facility. A current falls care plan, initiated 3/29/22, indicated at risk for falls related to muscle weakness, impaired balance, impaired cognition, forgetfulness to use walker,…
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 before2026-06-10 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
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 services provided by the facility met professional standards of quality for 2 of 3 closed records reviewed, and 1 of 4 residents observed for medication administration. Blood pressure medication and an inhaler were not administered as indicated in the physician's orders, and a urinary catheter was not placed as ordered. (Resident L, Resident F, Resident M) Findings include: 1. On 6/5/26 at 2:33 P.M., Resident M's clinical record was reviewed. Diagnoses included, but were not limited to, obstructive and reflux uropathy and hydronephrosis. The current Quarterly Minimum Data Set (MDS) Assessment, dated 5/11/26, indicated Resident M was cognitively intact and had an indwelling catheter. Current physician orders included, but were not limited to:May change foley catheter every 21 day and as needed (prn) due to occlusion one time a day every 21 day(s) for obstructive uropathy foley maintenance, dated 3/26/26. Foley catheter size 16 fr (french)/10cc (cubic centimeters) due to diagnosis of urinary retention…
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 before2026-06-10 · 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 and standards were followed for 1 of 3 residents reviewed for urinary catheters and 1 of 1 residents reviewed for wounds. (Resident N and Resident R). Foley catheter tubing was observed on the ground and gloves were not changed between touching soiled surfaces and clean surfaces. Findings include: 1. On 6/4/26 at 11:59 A.M., Resident N was observed sitting in his wheelchair outside in the courtyard. A Foley catheter bag and tubing were hanging under the wheelchair. The tubing was observed touching the ground. At 12:14 P.M., Resident N wheeled himself inside. The catheter tubing dragged the ground into the building and continued to touch the floor once inside the facility. On 6/5/26 at 2:08 P.M., Resident N's clinical record was reviewed. Diagnoses included, but were not limited to, postpolio syndrome, benign prostatic hyperplasia (BPH), and paraplegia. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 3/19/26, indicated Resident N was cognitively intact,…
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 · E2025-04-25 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care plan conferences were completed quarterly for 13 of 25 residents admitted reviewed for care plans. (Resident 1, Resident 16, Resident 14, Resident 22, Resident 17, Resident 26, Resident 42, Resident 45, Resident 49, Resident 75, Resident 99, Resident 105, Resident 115) Findings include: 1. On 4/22/25 at 9:03 A.M., Resident 26 indicated that the facility did not involve her in reviewing her care plan and that she did not attend care plan conference meetings quarterly. On 4/23/25 at 9:27 A.M., Resident 26's clinical record was reviewed. Diagnosis included, but was not limited to, generalized anxiety disorder. The most current Quarterly MDS Assessment, dated 2/20/25, indicated Resident 26 was cognitively intact, was dependent on staff (staff does all the effort) for transfers, and received an antianxiety medication and opioid during the 7-day lookback period. The most recent care plan conference was dated 10/29/24. On 4/24/25 at 2:30 P.M., the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-04-25 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure safe and secure storage of all medications for 2 of 5 medication carts and 3 of 3 medication rooms observed. Medication refrigerator temperature logs were not filled out, loose pills were observed in medication carts, and medication carts were observed unlocked. (Horizons Unit, Harbor Unit, Wellsprings Unit) Findings include: 1. On 4/21/25 at 8:56 A.M., the Horizons Unit medication storage room was observed. A temperature log dated February 2025 and included a small fridge, small locked fridge, and large fridge, had temperatures listed for 2/1/25, and 2/16/25 through 2/18/25. All other dates were blank. The same form, dated April 2025, had temperatures listed for 4/16/25 through 4/18/25. All other dates were blank. A separate form dated February 2025 included the medication room temperature and a different refrigerator temperature. The form listed temperatures for 2/1/25. All other dates were blank. The same form, dated April 2025, had temperatures listed from 4/16/25 through 4/18/25. All other dates…
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 before2025-04-25 · tag F0880 — failed to prevent and control infections — patternProvide 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 a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for all residents. Hand washing was not adequately performed during medication administration, cups were handled by the rims during a meal observation, clean linen was not handled appropriately, and activity items were not washed after use. (Wellsprings Unit, Registered Nurse (RN) 42, Resident 89) Findings include: 1. During a medication pass on 4/24/25 at 7:52 A.M., RN 42 was observed to enter Resident 236's room with a medication cup of pills. RN 42 placed the medication cup on the bedside table, assisted the resident to put on her pants and shoes, then washed her hands for 11 seconds. RN 42 then obtained the resident's blood pressure, administered the medications in the cup, and assisted to insert the resident's hearing aides. 2. During a lunch observation on 4/21/25 from 11:47 A.M. through 12:15 P.M. on the Wellsprings Unit, the following was observed: Resident 89 was utilizing a cloth…
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 · D2025-04-25 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a resident's dignity was respected for 1 of 1 resident reviewed for dignity. A resident was told to urinate in her brief instead of being assisted to the toilet for staff convenience. (Resident 14) Finding includes: On 4/21/25 at 10:02 A.M., Resident 14 appeared to be teary. She indicated that she was upset about staff treatment of her the night of 4/20/25. She indicated that she was in bed and needed to use the toilet. An agency aide told her that she did not want to help her to the toilet and to urinate in her brief instead because she preferred to change the resident in bed. The resident indicated that she finally did urinate in her brief and the aide changed her. On 4/23/25 at 8:59 A.M., Resident 14's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's disease. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 2/24/25, indicated that Resident 14 was cognitively intact, required partial to moderate assistance of staff (staff does less than half of the effort)…
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 · D2025-04-25 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — the official record, unedited, 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 admission Minimum Data Set (MDS) Assessment was completed within 14 days of admission for 1 of 1 residents reviewed for new admissions. (Resident 335) Finding includes: On 4/22/25 at 1:30 P.M., Resident 335's clinical record was reviewed. Diagnosis included, but was not limited to, end stage renal disease. Resident 335 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) Assessment, dated 4/21/25, indicated it was still in process and not completed. The MDS dashboard included a warning that the admission MDS was overdue. On 4/24/25 at 2:30 P.M., the MDS Coordinator indicated that the facility's policy was to follow the Resident Assessment Instrument (RAI) Manual. The most current RAI Manual, dated October 2024, indicated that an admission MDS Assessment completion date was no later than the 14th calendar day of the resident's admission (admission date + 13 calendar days). 3.1-31(d)(1)
- Potential for harm · D2025-04-25 · tag F0638 — isolatedAssure that each resident’s assessment is updated at least once every 3 months.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed no less than once every 3 months for 1 of 13 resident quarterly MDS assessments reviewed. (Resident 75) Finding includes: On 4/22/25 at 11:06 A.M., Resident 75's clinical record was reviewed. Diagnosis included, but was not limited to, stage 3 chronic kidney disease. The most recent completed MDS assessment was a significant change MDS assessment, dated 12/24/24. A quarterly MDS assessment, due 3/26/25, was still in progress (13 days late). 3.1-31(d)(3)
- Potential for harm · Dcited before2025-04-25 · 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 a resident's Minimum Data Set (MDS) Assessment was completed accurately for 1 of 5 residents reviewed for unnecessary medications. (Resident 4) Finding includes: On 4/22/25 at 12:27 P.M., Resident 4's clinical record was reviewed. Diagnoses included, but were not limited to, prediabetes and chronic pain syndrome. The most recent Annual Minimum Data Set (MDS) Assessment, dated 2/19/25, indicated Resident 4 was cognitively intact, received hypoglycemic medication during the 7-day look back period, and did not receive an anticonvulsant during the 7-day lookback period. Current physician orders included, but were not limited to: gabapentin (an anticonvulsant medication) oral capsule 100 milligrams (mg) - Give one capsule by mouth two times a day for pain, dated 1/31/25 The clinical record lacked an order for a hypoglycemic medication. On 4/24/25 at 2:14 P.M., the MDS Coordinator indicated that she marked hypoglycemic in error and meant to mark anticonvulsant. On 4/24/25 at 2:30 P.M., the MDS Coordinator indicated that…
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 before2025-04-25 · 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, interview, and record review, the facility failed to ensure the development of a resident's comprehensive care plan for 1 of 2 residents reviewed for Hospice and 1 of 1 residents reviewed for UTI. (Resident 45, Resident 22) Findings include 1. On 4/22/25 at 11:09 A.M., Resident 45's clinical record was reviewed. Diagnoses included, but were not limited to, transient cerebral ischemic attack, occlusion and stenosis of left middle cerebral artery, and need assistance with personal care. The current Annual Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident was severely cognitively impaired. Resident 45 was dependent on assistance for dressing, transferring and toileting. The current physician order included but was not limited to: Consult (name )Hospice for decline in health dated 3/6/25. There is no care plan for (name) Hospice for Resident 45. During an interview on 4/24/25 at 1:40 P.M., the Director of Nursing indicated there should be an initial care plan if 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.
Show the remaining 19 citations
- Potential for harm · Dcited before2025-04-25 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
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 neurological assessments were completed following unwitnessed falls for 2 of 2 residents reviewed for falls. Facility policy for completion of neurological assessments was not followed when staff failed to complete the required neurological assessments initially following a fall as well as follow-up assessments. (Resident 45, Resident 105) Findings include: 1. On 4/22/25 at 1:47 P.M., Resident 45's clinical record was reviewed. Diagnoses included, but were not limited to, muscle weakness (generalized), age-related osteoporosis without current pathological fracture, and history of falling. The current Annual MDS assessment dated [DATE] indicated that the resident was severely cognitively impaired. Resident 45 was dependent on assistance for dressing, transferring and toileting. The current physician orders included, but were not limited to: Dycem (anti-sliding device) in wheelchair to prevent sliding down in chair dated 3/16/25. Use no-skid mat…
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 · D2025-04-25 · 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 resident unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 1 of 4 residents reviewed for skin concerns. A resident with long toe nails had not been seen by podiatry or had toe nails trimmed. (Resident 124) Finding includes: On 4/22/25 at 12:30 P.M., Resident 124's clinical record was reviewed. admission date was 12/4/24. Diagnoses included, but were not limited to, Alzheimer's disease, dementia, anxiety, and depression. The most recent quarterly Minimum Data Set (MDS) assessment, dated 3/12/25, indicated a severe cognitive impairment. Resident 124 required substantial to maximum assistance (helper does more than half the effort) with showering. Current physician orders included, but were not limited to: May see podiatrist of choice, dated 12/4/24. A current ADL care plan, last revised 12/30/24, included, but was not limited to, an intervention to check nail length and trim and clean on bath day and as necessary,…
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 · D2025-04-25 · 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 observation, interview, and record review, the facility failed to ensure daily weights were completed to assess for complications of Congestive Heart Failure and a resident received thorough assessments for care of edema to lower extremities for 1 of 1 residents reviewed for edema. (Resident 22) Finding includes: During an observation on 4/22/25 at 8:46 A.M., Resident 22's bilateral lower legs were observed to have edema. Resident 22 indicated she was not weighed daily and sometimes has to ask for her second edema pill because staff will only bring her one. On 4/22/25 at 12:58 P.M., Resident 22's clinical record was reviewed. Diagnoses included, but were not limited to, congestive heart failure (CHF), and urinary tract infection. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 3/19/25, indicated Resident 22 was cognitively intact, required supervision from staff for toileting, required partial assistance from staff (staff do some of the work) for transfers, and was frequently incontinent of urine. Physician orders included, but were not limited 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 before2025-04-25 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure treatment and services were provided to prevent urinary tract infections (UTI) for 1 of 5 residents reviewed for UTIs. The physician was not notified of a suspected UTI, a resident with increased symptoms was not tested for a UTI, an antibiotic was given without a culture, and the resident received double the amount of an antibiotic as ordered. (Resident 102) Findings include: On 4/22/25 at 11:11 A.M., Resident 102's clinical record was reviewed. Resident was admitted [DATE]. Diagnosis included, but were not limited to, Alzheimer's disease. The most recent admission Minimum Data Set (MDS) assessment, dated 3/18/25, indicated a severe cognitive impairment. Resident 102 required partial to moderate assistance (helper does less than half the effort) with toileting and showering. The resident was frequently incontinent of bladder and bowel. Physician orders included, but were not limited to: Ceftriaxone (Rocephin) (an antibiotic) 1 gm…
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 · D2025-04-25 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure dietitian recommendations were implemented to prevent unnecessary weight loss for 1 of 3 residents reviewed for nutrition. (Resident 49) Finding includes: On 4/23/25 at 9:35 A.M., Resident 49's clinical record was reviewed. Resident 49 was admitted on [DATE]. Diagnosis included, but were not limited to, cerebral infarction. The most recent Quarterly MDS Assessment, dated 2/28/25, indicated Resident 49 was moderately cognitively intact and was dependent on staff (staff do all of the work) for toileting, bathing, and transfers, required set-up assistance from staff for eating, and had experienced unexpected weight loss. The clinical record indicated Resident 49 had lost 21.44% body weight from 10/4/24 (147.4 pounds) to 4/1/25 (115.8 pounds). On 12/20/24 1:01 P.M., the Registered Dietitian (RD) entered a progress note that indicated RD reviewed weight loss and intake, requesting to start 90 Milliliters (ml) Med Pass (nutritional supplement) BID.…
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 · D2025-04-25 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from unnecessary medications for 3 of 4 residents reviewed for as needed (PRN) antianxiety medications. Residents' PRN antianxiety medications were ordered for greater than 14 days. (Resident 16, Resident 23, and Resident 102) Findings include: 1. On 4/22/25 at 2:11 P.M., Resident 16's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety disorder. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 2/19/25, indicated Resident 16 was not assessed for cognitive impairment because she was rarely or never understood, was dependent on staff (staff does all the effort) for Activities of Daily Living (ADLs), and did not receive an antianxiety medication during the 7-day look back period. Current physician orders included, but were not limited to: Ativan (an antianxiety medication) solution 2 milligrams per milliliter (mg/ml) - Give 0.25 ml sublingually every two hours as needed for…
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 · D2025-04-25 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
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 establish a complete stewardship program for antibiotic use to ensure antibiotics ordered by a physician were given as ordered and that appropriate antibiotics were given based on culture results for 3 of 4 residents reviewed for urinary tract infections. (Resident 22, Resident 75, and Resident 42) Findings include: 1. During an interview on 4/22/25 at 8:39 A.M., Resident 22 indicated she had an ongoing burning pain in her bladder. On 4/22/25 at 12:58 P.M., Resident 22's clinical record was reviewed. Resident 22 was admitted on [DATE]. Diagnosis included, but was not limited to, urinary tract infection (UTI). The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 3/19/25, indicated Resident 22 was cognitively intact, required supervision from staff for toileting, required partial assistance from staff (staff do some of the work) for transfers, and was frequently incontinent of urine. Resident 22's clinical record lacked a care plan related…
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 before2024-03-19 · 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 observation, interview and record review, the facility failed to ensure the MDS (Minimum Data Set) Assessment was completed accurately for 1 of 1 resident reviewed for elopement and 1 of 5 residents reviewed for falls. (Resident 117, Resident 115) Findings include: 1. On 3/15/24 at 9:30 A.M., Resident 117's clinical record was reviewed. Diagnosis included, but was not limited to, dementia. The most recently Quarterly MDS Assessment, dated 12/29/23, indicated Resident 117 had severely impaired cognition and did not use a wander/elopement alarm during the 7-day look back period. Physician orders included, but were not limited to: Secure Care bracelet applied to right ankle. Check placement per nursing measure. Expiration: May 2024, dated 3/15/24. Secure Care bracelet applied to ankle. Check placement per nursing measure every shift for Elopement Prevention, starting 8/23/2023 and discontinued on 3/15/24. The December 2023 TAR (treatment administration record) indicated Resident 117's Secure Care bracelet was applied and checked three times daily in December except on 12/17/23…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-19 · 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 record review, interview, the facility failed to ensure preventative measures were in place or orders were followed to prevent an ulcer from forming and progressing for 1 of 2 residents reviewed for facility acquired skin ulcers. (Resident 11) Findings include: On 3/14/24 at 8:26 A.M., Resident 11's clinical record was reviewed. Diagnoses included, but were not limited to, type 2 diabetes mellitus, Alzheimer's disease, and restless leg syndrome. The most recent Quarterly MDS Assessment, dated 2/20/24, indicated Resident 11 was cognitively intact, required extensive assistance of two staff for mobility, transfers, and toileting, and was receiving oxygen therapy. Current physician orders included, but were not limited to: Daily skin check If any new area of skin impairment found, follow altered skin integrity policy. Every day make note if new area found. Start date 1/20/24. Cleanse daily with normal saline, Betadine, and apply foam dressing every shift for left achilles pressure area. Start date 3/7/24. Assess left Achilles Pressure ulcer and dressing daily. Start 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 before2024-03-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received consistent implementation of interventions to prevent falls for 2 of 5 residents reviewed for accidents related to falls. Fall interventions were observed out of place, and care plans were not updated following falls. (Resident 115, Resident 86) Findings include: 1. On 3/13/24 at 2:50 P.M., Resident 115's clinical record was reviewed. The resident was admitted to the facility on [DATE] following surgical repair of a right shoulder fracture from a fall that occurred at the resident's home. Diagnoses included, but were not limited to, dementia and history of falling. The most recent full admission MDS (Minimum Data Set) Assessment, dated 9/12/23, indicated Resident 115 had severe cognitive impairment, required extensive assistance of 2 or more staff for bed mobility and transfers, required extensive assistance of 1 or more staff for toileting, and had fallen resulting in a fracture in the 6 months prior 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 · D2024-03-19 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure the appropriate care of the PEG (Percutaneous Endoscopic Gastromy)/ G-tube (Gastromy) tube feeding tubing for 1 of 2 residents. The tubing lacked a date when changed, label of contents, and initials of the nursing staff. (Resident 1) Findings include: On 3/12/24 at 1:07 P.M., Resident 1's tube feeding container was observed hanging in the room on an IV pole on a pump. The feeding bag lacked a label of what the formula was and a date of when the tubing was changed. On 3/13/24 at 1:10 P.M., Resident 1's tube feeding container was observed hanging in the room on an IV pole on a pump. The feeding bag lacked a label of what the formula was and a date of when the tubing was changed. On 3/13/24 at 2:53 P.M., Resident 1's clinical record was reviewed. Diagnoses included but were not limited to, diffuse traumatic brain injury with loss of consciousness greater than 24 hours with return to pre-existing conscious level and persistent…
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 · D2024-03-19 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure oxygen equipment was properly labeled and oxygen properly administered for 3 of 6 residents at risk for respiratory complications. (Resident 10, Resident 55, Resident 11 ) Findings include: 1. On 3/12/24 at 1:30 P.M., an oxygen humidification water bottle dated 3/5/24 without an oxygen storage bag was observed in Resident 10's room. On 3/13/24 at 1:03 P.M., an oxygen humidification water bottle dated 3/5/24 without a oxygen storage bag was observed in Resident 10's room. On 3/13/24 at 12:46 P.M., Resident 10's clinical record was reviewed. Diagnoses included but were not limited to, malignant neoplasm of unspecified part of bronchus or lung and chronic pain syndrome. The current Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated the resident was severely cognitively impaired, needed extensive assistance with 2 people for mobility, transfer, and toileting, and used oxygen. Current physician orders included but were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-01 · 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 ensure an allegation of abuse was reported to the facility administrator in the required time frame for 1 of 2 allegations of staff to resident abuse reviewed. The facility administrator was not made aware of an allegation of physical and verbal abuse until 20 days after the alleged abuse occurred. (Resident D) Finding includes: During a review of reportable incidents on 10/31/23 at 11:30 A.M., a reported incident dated 9/21/23 included that on 9/21/23, CNA 4 stated that three weeks prior, CNA 6 was rough with Resident D during a transfer and threw the resident's legs in bed, and that CNA 6 was overheard telling residents to shut up on 9/1/23 around 5:00 A.M. During an interview on 10/31/23 at 10:40 A.M., CNA 9 stated that if perceived resident abuse is observed, or if a resident alleges abuse, the allegation should be reported immediately. On 11/1/23 at 9:15 A.M., the facility administrator supplied a facility policy tilted, Abuse Prohibition, dated 11/22/22. The policy included, .All allegations/suspicions/reports of…
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 · E2022-07-05 · tag F0688 — failed to keep residents mobile / prevent decline — patternProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents with limited mobility received appropriate services. Residents did not receive restorative nursing services for 7 of 7 residents reviewed for mobility. ( Resident 1, Resident 5, Resident 16, Resident 66, Resident 75, Resident 76, Resident 85) Findings include: 1. On 6/28/22 at 9:20 a.m., Resident 1 was observed in her room. She was observed to have a flaccid left arm. Resident 1 did not answer questions when spoken to. On 6/30/22 at 6:12 a.m., Resident 1's clinical record was reviewed. She had diagnoses that included, not limited to, other sequelae of cerebral infarction, other abnormalities of gait and mobility, unspecified lack of coordination, hemiplegia and hemiparesis following cerebral infarction affecting left non dominate side, stiffness of left wrist. A quarterly MDS (Minimum Data Set), assessment dated [DATE], indicated Resident 1's cognition was intact, had range of motion (ROM) impairment on one side upper 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 · Dcited before2022-07-05 · 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
Based on observation, interview, and record review, the facility failed to ensure physician orders were followed for 1 of 1 residents reviewed for weights. Daily weights were not taken or sent to the physician as ordered, Tubi grips were not provided for edema to the lower legs. (Resident 29) Finding includes: On 6/30/22 at 8:15 a.m., Resident 29 was observed in her room eating breakfast, no Tubi-grips were observed on her lower legs. On 7/1/22 at 9:48 a.m., Resident 29 was observed in her room, no Tubi-grips were observed on her lower legs. On 7/5/22 at 12:43 p.m., Resident 29 was observed in her room, no Tubi-grips were observed on her lower legs. On 6/29/22 at 10:30 a.m., Resident 29's clinical record was reviewed. Diagnoses included, not limited to, Chronic Obstructive Pulmonary Disease, Alzheimer's disease, unspecified dementia without behavioral disturbance, unspecified cognitive communication deficit. A quarterly MDS (minimum Data Set), dated 6/20/22 indicated Resident 29's cognition was severely impaired. Care plans were reviewed and included, not limited to: I am at risk…
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 before2022-07-05 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were maintained during care for 2 of 4 residents reviewed with catheters and obtained urinary infections. A catheter bag and tubing were observed hanging on the trashcan and resting on the floor. (Resident 65, Resident 72) Findings include: 1. During an observation on 6/27/22 at 10:38 A.M., Resident 65 was observed sitting in her recliner with her catheter bag hanging on the trashcan. The trashcan had used tissues and a cereal box in it. At that time, Resident 65 indicated that the catheter is always hung from the trashcan, and she currently has a UTI (urinary tract infection). During an observation on 6/28/22 at 8:19 A.M., Resident 65's catheter bag was hung on the trashcan. The trashcan had used purple disposable gloves and tissues in it. During an observation on 6/29/22 at 1:19 P.M., Resident 65's catheter bag was hung on the trashcan. The trashcan had used purple disposable gloves 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 · D2022-07-05 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure food was served in a sanitary manner in accordance with professional standards for food service safety in 2 of 2 observations of the kitchen and meal service. Staff did not perform adequate hand hygiene, staff did not cover hair with hairnets while in the kitchen, the paint on the ceiling was chipping, and food items were out of date. (Main Dining Room) Findings include: 1. On 6/27/22 at 8:54 A.M., the following food items were observed on a rack in the dry storage room: An open package of Nilla Wafers with the dates 4/19 and 5/19 written on it A bag of confectioners sugar with the dates 5/14 and 6/14 At that time, the Kitchen Manager indicated the Nilla Wafers and confectioners sugar were not supposed to be in the dry storage, and removed them. 2. On 6/27/22 at 8:54 A.M., Kitchen Aide 21 was observed in the kitchen with a hairnet on. The hairnet was not covering all of the hair, with the bottom half of the head exposed. During the lunch service on 6/30/22 at 10:47 A.M., the following was observed in…
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 · Ccited before2024-03-19 · tag F0732 — widespreadPost nurse staffing information every day.
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 post the actual shift times worked of licensed and unlicensed nursing staff directly responsible for resident care per shift daily for 9 of 9 days reviewed. Finding includes: During an observation, on 3/15/24 at 1:11 P.M., the staff numbers posted at the Harbor nurses station reflected the census was 126 residents. The form indicated staff worked one half or three quarters of a shift and did not include the actual shift times worked by nursing staff. On 3/19/24 at 11:23 A.M., staff posting sheets were provided by the Administrator for the following dates: 3/11/24 3/12/24 3/13/14 3/14/24 3/15/24 3/16/24 3/17/24 3/18/24 3/19/24 Each staff posting sheet included the date, census, and total hours each discipline was in the building. Disciplines included RN (registered nurse), LPN (licensed practical nurse), QMA (qualified medication aide), and CNA (certified nursing aide). The actual shifts worked by each shift were not included on the sheets. During an interview on 3/19/24 at 11:48 A.M., the Administrator…
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 · Ccited before2022-07-05 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure completed staffing sheets were posted daily for 6 of 6 days during the survey for 3 of 3 units. (Harbor Unit, Wellsprings Unit, Horizons Unit) Findings include: On 6/28/22 at 10:50 A.M., a staffing sheet was observed to be posted by the Harbor Unit nurses station. The staffing sheet indicated the date, total facility census, and total hours worked each shift. Disciplines included LPN, RN, QMA, and CNA. Specific number of staff and exact hours worked were not included in the posting. On 6/30/22 at 8:12 AM., a staffing sheet was observed to be posted by the Wellsprings Unit nurses station. The staffing sheet indicated the date, total facility census, and total hours worked each shift. Disciplines included LPN, RN, QMA, and CNA. Specific number of staff and exact hours worked were not included in the posting. No staff posting was observed on the Horizons Unit. On 7/5/22 at 1:00 P.M., staff posting sheets were provided for the following dates: 6/24/22 6/25/22 6/26/22 6/27/22 6/28/22 6/29/22 6/30/22 7/1/22…
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 |
|---|---|---|---|---|
| PULASKI MEMORIAL HOSPITAL | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 02/01/2023 |
| STRICKLAND, ADAM | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 02/01/2023 |
| JAROSINSKI, STEPHEN | Individual | CORPORATE OFFICER | — | since 02/01/2023 |
| MALOTT, GREGG | Individual | CORPORATE OFFICER | — | since 02/01/2023 |
| HOLIDAY HOME HEALTH CARE CORPORATION OF EVANSVILLE | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 02/01/2023 |
2 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 $4.4M paid to related parties — landlords or management companies under common ownership — equal to about 29% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
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 155104. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-25, 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.