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North Park Nursing Center

650 Fairway Dr, Evansville, IN 47710 · Non profit - Other · 103 certified beds · (812) 425-5243 Medicare & Medicaid certified

Call the home — (812) 425-5243 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
2 actual-harm citations$38,288 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $38,288 in federal fines (most recent 2024-08-29)
  • its facility-reported quality-measure score sits well above its independent inspection score

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 5 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

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3844 N 1st Ave · (812) 428-6161 · Call to confirm hours
Pharmacy
3408 N First Ave · (812) 422-8255 · Call to confirm hours
Grocery
3700 N 1st Ave · (812) 464-3920 · Call to confirm hours
Park
1100 Fulton Pkwy · (812) 435-6141 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased4.2%11.0%15.4%better
Long-stay residents who lose too much weight6.8%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.2%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.3%1.1%2.0%better
Long-stay residents with depressive symptoms26.2%25.2%6.5%typical for the state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury6.9%3.9%3.3%worse
Long-stay residents whose ability to walk worsened5.6%11.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication24.2%23.5%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.4%95.3%typical
Long-stay residents with pressure ulcers3.3%3.6%4.7%better
Long-stay residents with worsening bladder/bowel control17.7%23.3%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table4.0%13.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine95.8%79.0%79.4%better
Long-stay hospitalizations per 1,000 resident days2.331.611.67worse
Long-stay outpatient ER visits per 1,000 resident days0.831.441.80better

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.

60.4% 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 38 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

60.4%U.S. median 51.5%
Got home and stayed home
9.1%U.S. median 10.7%
Went back to hospital
0.21U.S. median 0.31
Therapy hours / resident / day
0.03hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.21 therapist hours per resident per day in 2026Q1 — more than 24% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF60.4%CMS range 44.7–74.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.1%CMS range 5.7–13.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS 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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.4%CMS range 3.4–12.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.901.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.62
RN hours/ resident / day
0.71
LPN hours/ resident / day
2.59
Aide hours/ resident / day
3.91
Total nurse hours/ resident / day
0.49
RN hoursweekends
44.7%
Total nursing turnover
9.1%
RN turnover

How full it usually is: this home is certified for 103 beds and averages 85.0 residents a day — about 83% occupied, or roughly 18 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 3.91 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.62 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.59 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 3.05 hrs/resident/day on weekends vs 4.26 on weekdays — 28% thinner on weekends — a notable drop. RN hours go from 0.67 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 45% 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

0
deficiencies at the latest standard inspection (2025-11-21)
11
at the previous standard inspection (2024-08-29)

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.

ABCDEFGHIJKL

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

26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.

  • Actual harm · G2024-08-29 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 without diabetes was free from a significant medication error for 1 of 1 resident reviewed for significant medication errors. (Resident L) This deficient practice resulted in Resident L receiving an overdose of rapid-acting and long-acting insulins and a significant change in condition that required emergent, intensive care at an acute care hospital for treatment of low blood sugar. Finding includes: On 8/22/24 at 2:40 P.M., Resident L's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease. The resident did not have a diagnosis of diabetes. A Quarterly Minimum Data Set (MDS) Assessment, dated 4/1/24, indicated Resident L was not assessed for cognitive ability because the resident was rarely or never understood, was dependent on staff for eating, did not have insulin orders, and did not receive any insulin injections during the 7-day look back period. The physician orders, dated 5/1/24 to 8/22/24, did not include documentation to indicate Resident L had a diagnosis…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2023-05-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident received supervision and consistent implementation of interventions to prevent falls for 1 of 3 residents reviewed for falls. Resident 31 had a fall that resulted in a fracture to right femur. (Resident 31) Finding includes: During an interview on 5/21/23 at 11:14 A.M., Resident 31's spouse indicated Resident 31 had fallen several times and recently had a fall that resulted in sutures and staples. He was concerned that the falls resulted from a lack of staffing on the unit. He indicated he had been to management several times with the concern, and was told that Resident 31's falls could have been prevented if there was more staff. He indicated during the most recent fall, the CNA (Certified Nurse Aide) had left all the residents on the hall to get report from another CNA in another hall. At that time, Resident 31 was in her room and had gotten up by herself to walk toward the door. Her alarm was sounding, but because…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent falls for 2 of 3 residents reviewed for accidents. Following a significant decline, a dependent resident was encouraged to participate in dressing which resulted in a fall, and a resident's care plan intervention was not in place to prevent an additional fall. (Resident C, Resident D)Findings include: 1. A record review on 12/22/25 at 1:40 P.M. indicated Resident C's diagnoses included, but were not limited to, vascular dementia with agitation, anxiety disorder, muscle weakness, and unsteadiness on feet.Resident C's Significant Change Minimum Data Set (MDS) assessment, dated 8/20/25, indicated the resident required set-up assistance with the Activity of Daily Living (ADL) of upper and lower body dressing. Resident C's most recent Significant Change MDS, dated [DATE], indicated the resident had significant cognitive impairment, was dependent (helper does ALL of the effort. Resident does none of the effort to complete the activity…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-07 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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 implement a resident's plan of care for 1 of 3 residents reviewed for accidents. A resident's care plan intervention to reduce a risk for falls was not in place for a resident with a recent fall. (Resident D)Finding includes:During an observation and interview on 8/6/25 at 8:45 A.M., Resident D was sitting up in her bed with a breakfast tray in front of her. The resident indicated she was not sure how long she had been in the facility and that she was not sure how much assistance she needed to get out of bed. During an interview on 8/6/25 at 9:30 A.M., LPN 2 indicated that Resident D had a recent fall and had occasional falls due to attempting to transfer herself in her room. Record review on 8/6/25 at 11:00 A.M., Resident D's diagnoses included but were not limited to hemiplegia and hemiparesis following cerebral infarction, depression, need for assistance with personal care, muscle weakness, abnormalities of gait and mobility, and unsteadiness on feet. Resident D's most recent quarterly 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-07 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure staff performed proper hand hygiene and sanitation during care for 3 of 4 resident care observations. Staff failed to perform hand hygiene between glove changes and failed to perform hand hygiene immediately following care and prior to touching resident belongings and room door handles. (Resident B, Resident C, Resident F) Findings include: 1. On 8/6/25 at 2:02 P.M., LPN 2 was observed providing wound care to Resident B's lower extremities. Resident B was observed sitting in bed. LPN 2 gave a clear plastic trash bag to Resident B to hold. LPN was observed during the treatment of the wounds to dispose of the old, soiled dressings and supplies into the bag that Resident B was holding on his lap. On 8/6/25 at 2:34 P.M., the Infection Preventionist Nurse indicated that she would have put a trash can at the end of the bed to drop the soiled dressing in. On 8/7/25 at 2:48 p.m., the Infection Preventionist Nurse provided the current skills competency nursing policy and procedure for dressing change clean…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent accidents for 1 of 3 residents reviewed for falls. The plan of care was not followed while transferring a resident to obtain a weight chair when a fall occurred. ( Resident C) Finding includes: On 6/12/25 at 11:20 a.m., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, nontraumatic intercranial hemmorrhage, unspecified, diabetes mellitus with hyperglycemia, polyneuropathy in diseases classified elsewhere, morbid obesity. A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated cognition intact, sit to stand substantial/maximal assist (sit to stand: the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.) Chair/bed -to-chair transfer- substantial/maximal assist (the ability to transfer to and from a bed to a chair (or wheelchair). Toilet transfer- substantial/maximal assist-(the ability to get on and off a toilet or commode.) Care…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-21 · tag F0635 — isolated
    Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a newly admitted resident had immediate orders for wounds for 1 of 3 residents reviewed for wounds. (Resident B) Finding includes: On 3/20/25 at 8:44 a.m., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, hemiplegia and hemaparesis following cerebral infarction affecting right dominant side, dysphagia following cerebral infarction,chronic obstructive pulmonary disease, unspecified protein-calorie malnutrition, hyperlipidemia. An admission Minimum Data Set (MDS) assessment dated [DATE], indicated Resident B's cognition was intact, range of motion, impairment one side upper and lower extremities. Pressure injury, 2 unstageable deep tissue injury present on admission. Resident B admitted to the facility on [DATE], discharged on 12/4/24. Care plans included, but were not limited to: [Resident B] is at risk for skin breakdown or further skin breakdown due to refuses showers at times. Responds to verbal commands…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-29 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure that medications were properly stored and labeled in 2 of 6 medication carts and 2 of 2 treatment carts observed. (E-Hall, F-Hall, Short Hall Cottage Treatment Cart, A-Hall Treatment Cart) Findings include: 1. On 8/21/24 at 8:50 A.M., the following loose pill was observed in the E-Hall Medication Cart for rooms 141-147: 1/2 small round white pill 2. On 8/21/24 at 8:55 A.M., the following loose pills and unlabeled medications were observed in the E-Hall Medication Cart for rooms 131-140: 2 1/2 small round white pills 1 bottle of Honey Robitussin (cough medicine) with [Resident 33] on bottle but no label or open date 3. On 8/21/24 at 9:05 A.M., the following unlabeled materials were observed in the Short Hall of the Cottage: 1 Honey Dressing (medicated) package no label or open date 4. On 8/21/24 at 9:25 A.M., the following unlabeled materials were observed in the A-Hall Treatment Cart: 1 tube of opened antifungal cream for [Resident 27] no label 1 bottle of wound cleaner open with [Resident 8] no label…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-29 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure 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 that food was served at palatable temperatures for 1 of 1 trays tested for temperature. (A-Hall) Finding includes: On 8/21/24 at 10:06 A.M., Resident Q indicated the food was always cold. On 8/21/24 at 10:44 A.M., Resident 36 indicated the food was usually cold. On 8/21/24 at 2:20 P.M., Resident 33 indicated the food was cold all the time. On 8/23/24 at 1:06 P.M., a test tray was obtained. Food temperatures for that meal were: chicken 114 F (Fahrenheit) fries 109 F coleslaw 55.5 F mandarin oranges 60 F On 8/29/24 at 8:50 A.M., the Dietary Manager indicated food temperatures should be palatable. On 8/29/24 at 10:51 A.M., the Administrator provided a Food Temperatures policy, revised 6/23, that indicated All hot and cold food items will be served to the resident at a temperature that is considered palatable at the time the resident receives the food. The Retail Food Establishment Sanitation Requirements 410 IAC 7-24 Sec. 166, effective November 13, 2004, indicated (a) .refrigerated, potentially hazardous…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-29 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure dishwasher temperatures were within range and food was prepared under sanitary conditions for 1 of 1 kitchens observed. The temperature on the final rinse of the dishwasher did not reach required levels, hairnets did not cover hair, and staff touched food with their bare hands. (Kitchen, [NAME] 10, Dietary Aide 25) Findings include: 1. On 8/21/24 at 8:45 A.M., a dishwasher cycle was observed. The final rinse reached 173 degrees Fahrenheit (F). On 8/21/24 at 10:36 A.M., the Dietary Manager indicated the regulation stated the dishwasher final rinse needed to reach 180 F, but the manufacturer said 175 F was acceptable. A service technician had been called that morning. At that time, a high temp dishmachine temperature log was provided. Final rinse temperatures recorded for the month of August ranged from 168 F to 178 F. On 8/29/24 at 10:51 A.M., the Administrator provided a Work Order for the dishwasher, dated 8/21/24, that indicated Customer stated that dish machine was not getting to 180 degrees. Upon…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-29 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure documentation was complete for 5 of 6 residents reviewed for medications. Medications on the Medication Administration Record (MAR) were not documented as completed. (Resident M, Resident N, Resident Q, Resident 86, and Resident 45) Findings include: 1. On 8/26/24 at 2:35 P.M., Resident M's clinical record was reviewed. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, diabetes mellitus, generalized anxiety disorder, chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity, and chronic pain syndrome. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 7/5/24, indicated Resident M was cognitively intact, required supervision for eating, and received an antianxiety medication, anticoagulant, opioid, and insulin during the 7-day look back period. Physician orders included, but were not limited to: insulin lispro (a rapid-acting insulin) - insulin pen; 100 unit/mL (units per milliliter) -…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-29 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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

    Based on interview and record review, the facility failed to ensure care plan conferences were completed for 3 of 3 residents reviewed for care plan conferences. (Resident M, Resident N, Resident Q) Findings include: 1. On 8/26/24 at 2:35 P.M., Resident M's clinical record was reviewed. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, diabetes mellitus, generalized anxiety disorder, and depression. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 7/5/24, indicated Resident M was cognitively intact and was dependent on staff for toileting, and required substantial to maximal assistance of staff (staff does more than half) for bed mobility and bathing. The clinical record lacked documented care plan conferences between 5/9/23 and 11/6/23. 2. On 8/21/24 at 1:59 P.M., Resident N indicated he did not have care plan meetings to discuss his care. On 8/22/24 at 11:33 A.M., Resident N's clinical record was reviewed. Diagnoses included, but were not limited to, chronic kidney disease,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · D2024-08-29 · tag F0659 — isolated
    Provide care by qualified persons according to each resident's written 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 staff were qualified to administer insulin to residents for 3 of 6 residents reviewed for insulin. Qualified Medication Aides (QMAs) who were not insulin certified, administered insulin to residents and held insulin without a physician order or notification of nursing staff. (Resident N, Resident M, and Resident Q) Findings include: 1. On 8/26/24 2:35 P.M., Resident M's clinical record was reviewed. Diagnosis included, but was not limited to, diabetes mellitus. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 7/5/24, indicated Resident M was cognitively intact and received insulin during the 7-day look back period. Physician orders included, but were not limited to: insulin lispro (a fast-acting insulin) - insulin pen; 100 unit/mL (units per milliliter) - give 10 units subcutaneous three times a day. Notify MD (Medical Doctor) if blood glucose is below 70 mg/dL (milligrams per deciliter) or above 400 mg/dL, dated 8/27/22. The February 2024 MAR (Medication Administration Record) indicated: QMA 8…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-29 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure residents dependent on staff for ADL (activities of daily living) were showered for 2 of 2 residents reviewed for ADL care. (Resident 33 and Resident Q) Findings include: 1. On 8/21/24 at 2:21 P.M., Resident 33 indicated that she did not get showers, and that staff only give her bed baths. She further indicated that she didn't feel clean. On 8/22/24 at 1:41 P.M., Resident 33's clinical record was reviewed. Diagnoses included, but were not limited to, hypertensive chronic kidney disease and diabetes mellitus. The most current Quarterly MDS (Minimum Data Set) Assessment, dated 8/9/24, indicated Resident 33 was cognitively intact, required substantial to maximal assistance of staff (staff does more than half) for bathing, and had no rejection of care. An Assistance with ADLs care plan, dated 6/2/24, indicated for staff to assist with bathing as needed per resident preference. Offer showers two times per week, partial bed bath in between. A Preferences for Customary Routine and Activities assessment, dated 8/9/24,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-29 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure through assessments were completed for 1 of 1 residents receiving a diuretic for congestive heart failure. Daily weights were not obtained as ordered. (Resident 36) Finding includes: On 8/27/24 at 10:27 A.M., Resident 36's clinical record was reviewed. Diagnoses included, but were not limited to, chronic systolic (congestive) heart failure, localized edema, primary pulmonary hypertension. A quarterly MDS (Minimum Data Set) assessment, dated 7/5/24, indicated Resident 36's cognition was intact and received a diuretic medication. June and July 2024 physician orders and the EMAR (Electronic Medication Administration Record) were reviewed and included but was not limited to: Daily weight for CHF (congestive heart failure), once a day. Notify MD (Medical Doctor) of weight gain of 3 lbs. (pounds) a day or 5 lbs. in a week, start date 11/25/23, discontinued 7/13/24. June dates not documented: 6/3, 6/12, 6/13, 6/22, 6/27. 6/28, 6/30. July dates not documented: 7/4, 7/5, 7/6, 7/8, 7/10. Weights were reviewed and included,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-29 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure staff performed proper hand hygiene and disinfection of equipment during 2 of 2 random observations of resident care. (Resident 9) Findings include: 1. On 8/23/24 at 6:45 A.M., CNA (Certified Nursing Aide) 18 and CNA 4 were observed performing peri care for Resident 9. CNA 18 had gloves on and touched the nightstand and bedside table. CNA 4 turned Resident 9 to the right side and removed the soiled brief. CNA 18 cleaned Resident 9's buttocks with wipes and placed the soiled brief in a plastic bag. After placing the soiled brief in the plastic bag and without changing gloves, CNA 4 placed barrier cream on the resident's buttocks and positioned a new brief. CNA 4 donned new gloves without sanitizing or washing hands, applied cream to scrotal area with same gloves, and attached a clean brief. CNA 18 and CNA 4 did not change gloves before touching and placing clean clothes on Resident 9. CNA 4 removed gloves and placed the Hoyer pad under Resident 9 without hand sanitizing and proceeded to touch controls.…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-30 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide ADL (activities of daily living) care for 3 of 3 resident's reviewed for bathing. Bathing was not provided to residents. ( Resident B, Resident C, Resident D ) Finding includes: 1. On 1/29/24 at 9:50 a.m., Resident B indicated his showers are lacking, he has had a few bed baths, staff helped him change his diaper and get dressed that morning so he could go to therapy. Resident B indicated staff handed him his deodorant and he put it on, but did not wash him including using wipes on his bottom. Resident B indicated when was at home he took two showers a day. On 1/29/24 at 11:24 a.m., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, acute metabolic acidosis, chronic obstructive pulmonary disease, hypertensive heart disease with heart failure. Resident B was admitted to the facility on [DATE]. An admission MDS (Minimum Data Set) assessment, dated 12/21/23, indicated Resident D's cognition was 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-12 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure accurate and complete documentation was recorded on the EMAR (Electronic Medication Administration Record) for 5 of 7 residents reviewed for medications. Medications were not documented as given. ( Resident D, Resident E, Resident F, Resident H, Resident J) Finding includes: On 10/13/23 at 9:30 a.m., the clinical record was reviewed for resident's chosen for medication review. The following medications were not documented as given on the dates listed: Resident D: 8/23/23 - clonazepam 0.5 mg oral three times a day 6:00 a.m., 3:00 p.m., 11:00 p.m. The 11:00 p.m. dose was not documented as given. 8/23/23- hydrocodone-acetaminophen 7.5 mg -325 mg oral three times a day 6:00 a.m., 3:00 p.m., 11:00 p.m. The 11:00 p.m. dose was not documented as given. Resident E: Rezvoglar KwickPen (insulin glargine-agir) insulin pen; 100 unit/ml(milliliter) (3 ml); amount to administer 10 units subcutaneous at bedtime. The following dates were not documented as given: 8/8/23, 8/13/23, 8/19/23, 8/28/23, 9/17/23, 9/29/23.…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-05-25 · tag F0557 — pattern
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    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 maintain resident's dignity for 1 of 4 residents observed for incontinence care, and 1 of 2 observations of a meal. (Resident 62, Cottage Dining Room-Resident 41, Resident 75, Resident 70, Resident 31) Findings include: 1. On 5/23/23 at 9:51 A.M., CNA (Certified Nurse Aide) 25 and QMA (Qualified Medication Aid) 54 were observed to assist Resident 62 with incontinence care. During care, CNA 25 indicated At least he didn't get naked today. I shouldn't talk too soon. After checking Resident 62's brief, QMA 54 asked CNA 25 Are we going to need a new diaper?. After care was performed, CNA 25 indicated staff should respect resident dignity by speaking with the resident while performing care, explain what they were doing, and try to ease the resident. 2. On 5/25/23 at 8:13 A.M., breakfast was observed in the Cottage Dining Room of the dementia unit. At that time, there were 11 residents seated in the dining room. CNA 25 was observed speaking loudly to Therapist 41 about the residents sitting in the dining room. CNA…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-05-25 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure proper storage of medications for 3 of 3 medication carts observed. Loose pills were observed in the medication cart drawers (Cottage Unit, A Hall, F Hall). Findings include: 1. On 5/23/23 at 9:09 A.M., the Cottage Unit (Dementia unit) medication cart was reviewed. The following loose pills were observed in the bottom of the drawers: 1 yellow oval pill with marking 003 1 yellow circle pill with a heart marking 1 white circle pill with marking ML89 1 white oval pill with marking APO 2 dark yellow circle pills with marking C 1 white oval pill with marking 597 2 white circle pills with marking L150 4 brown with black specks circle pills with illegible markings 4 white circle pills with marking TCL340 At that time, QMA (Qualified Medication Aide) 15 indicated that a nurse is supposed to clean out the medication cart once a week. 2. On 5/23/23 at 9:18 A.M., the F Hall medication cart was reviewed. The following loose pills were observed in the bottom of the drawers: 1 red and white oval gel capsule 1 yellow…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-05-25 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed for 2 of 4 residents observed for incontinence care, and during medication administration. Gloves were not changed between dirty and clean tasks during care, and glucometer machines were not cleaned according to the cleaning packet instructions and facility policy. (Resident 62, Resident 29, Hall A medication cart) Findings include: 1. On 5/23/23 at 9:51 A.M., CNA (Certified Nurse Aid) 25 and QMA (Qualified Nurse Aid) 54 were observed to assist Resident 62 with incontinence care. Prior to touching the resident, CNA 25 sanitized her hands with hand sanitizer and put on a clean pair of gloves. CNA 25 then pulled the curtain, put a gait belt onto Resident 62, and assisted the resident into the bed. CNA 25 undressed the resident, and removed the used brief. With the same gloves, CNA wiped the resident during an active bowel movement, put on a clean brief, pulled up his pants, pulled up the blanket, and used the bed remote to lower the bed. CNA 25 then removed her…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-25 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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 who were self administering medications were assessed for capability to self administer medications and had orders for medication self-administration for 2 of 2 residents observed with medications in their rooms. (Resident 36 and Resident 51) Findings include: 1. During observation and interview on 5/22/23 at 10:15 A.M., Resident 51 was lying in bed. There was a small plastic cup of pills sitting on his bedside table. No staff were in or near the room. Resident indicated they were his pills and he did not know if he was going to take them. He did not take the pills during the interview. During an interview with the DON on 5/25/23 at 9:24 A.M., she indicated Resident 51 does not have a self-administration assessment or order and does not have the cognitive ability to self-administer his own medications. On 5/25/23 at 8:49 A.M., Resident 51's clinical records were reviewed. Diagnoses included, but were not limited to, encounter for orthopedic aftercare following surgical amputation above left…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-25 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide notification of change for 2 of 5 residents reviewed for notification. A resident's representative was not notified timely of an accident , and a representative was not notified of a letter a resident received related to a change of doctor. (Resident 62, Resident 35) Findings include: 1. During an interview on [DATE] at 11:11 A.M., Resident 62's daughter and POA (power of attorney) indicated she had not been notified of a recent fall in a timely manner. She indicated Resident 62 had fallen one evening and was sent to the ER (emergency room), where he received stitches to the forehead. She indicated the staff did not notify her until 3:00 A.M. the following morning. At that time, Resident 62 had already returned to the facility. On [DATE] at 8:55 A.M., Resident 62's clinical record was reviewed. Diagnosis included, but were not limited to, dementia, anxiety, and depression. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-25 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 resident privacy was maintained for 1 of 4 residents observed for medication administration, 1 of 5 residents observed for incontinence care, and 1 random observation. The privacy curtain and door were not shut during medication injection administration, the window curtains were not shut during incontinence care, and a computer screen was left up with resident information visible. (Resident 346 and Resident 62) Findings include: 1. On 5/23/23 at 7:05 A.M., a computer screen with resident information visible was observed unattended on the A Hall. Resident 346's information, including, but not limited to, name, age, date of birth , room number, and medication information, were visible on the computer screen. The computer screen was continuously observed until 7:47 A.M., when LPN (Licensed Practical Nurse) 3 entered the area and shut the computer screen. During the time of observation, housekeeping, therapy services, and nursing staff walked by the computer, and Registered Nurse (RN) 7 walked by 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-25 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure food was stored appropriately in 2 of 2 kitchen observations. Food containers were found not labeled in the the dry storage area, walk-in freezer, and 1 shelf in the kitchen area above the sink. (Kitchen) Findings include: On 5/21/23 between 8:45 A.M. and 9:15 A.M., during the initial kitchen tour the following was observed: Dry goods storage areas: box of 1/2 full box of chocolate caked mix that was open and not labeled. 1 large multiserving bottle of Heinz Ketchup, open, and undated. 1 large multiserving bottle of Heinz Mustard, open, and undated. 1 106 ounce large dented can of pumpkin dated 10/6 walk in freezer: 5 boxes of bread on the floor box of biscuits open, not dated On 5/21/23 between 9:15 A.M. and 9:30 A.M., during the initial kitchen tour the following was observed: 2 boxes of corn starch open, not dated. During an interview on 5/21/23 at 8:48 A.M., the dietary manager acknowledge that the boxes of bread should not be on the floor but on the milk crates. During an interview on 5/25/23 at 9:37 A.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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-08-29 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to post accurate actual hours worked for licensed and unlicensed nursing staff directly responsible for resident care per shift daily for 5 of 7 days during the annual survey period. Finding includes: During an observation on 8/23/24 at 12:33 P.M., a posted nurse staffing data sheet, dated 8/23/24, was observed on the main desk. The sheet included, but was not limited to, the following information: Census, total number of staff for each shift and total hours of each shift for CNA (Certified Nurse Aide), LPN (Licensed Practical Nurse), and RN (Registered Nurse). The sheet indicated that 9.5 unlicensed nursing staff worked the day shift but did not specify which half of the shift the staff worked. During an observation on 8/26/24 at 3:20 P.M., a posted nurse staffing data sheet, dated 8/26/24, was observed on the main desk. The sheet included, but was not limited to, the following information: Census, total number of staff for each shift and total hours of each shift for CNA (Certified Nurse Aide), LPN (Licensed…

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

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

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

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

Fines & penalties

$38,288 in federal fines across 1 penalty.

  • $38,288 — penalty dated 2024-08-29

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

Part of a chain

This home belongs to AMERICAN SENIOR COMMUNITIES — 90 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.9+0.1 vs chain
Health inspection 3 of 53.4-0.4 vs chain
Staffing 3 of 52.3+0.7 vs chain
Quality measures 5 of 54.7+0.3 vs chain
The other 89 homes this chain runs (chain average 3.9★, per CMS)
1 of 5Valparaiso Care & RehabilitationValparaiso, IN 2 of 5Arbor Grove VillageGreensburg, IN 2 of 5Bethany VillageIndianapolis, IN 2 of 5Columbia Healthcare CenterEvansville, IN 2 of 5Community Nursing And Rehabilitation CenterIndianapolis, IN 2 of 5Eagle Valley MeadowsIndianapolis, IN 2 of 5Harcourt Terrace Nursing And RehabilitationIndianapolis, IN 2 of 5Harrison TerraceIndianapolis, IN 2 of 5Hickory Creek At New CastleNew Castle, IN 2 of 5Maple Park VillageWestfield, IN 2 of 5Park Terrace VillageEvansville, IN 2 of 5Riverside VillageElkhart, IN 2 of 5Trailpoint VillageSouth Bend, IN 2 of 5University Nursing CenterUpland, IN 2 of 5Williamsport Nursing And RehabilitationWilliamsport, IN 3 of 5Allisonville MeadowsFishers, IN 3 of 5American VillageIndianapolis, IN 3 of 5Brownsburg MeadowsBrownsburg, IN 3 of 5Countryside MeadowsAvon, IN 3 of 5East Lake Nursing & Rehabilitation CenterElkhart, IN 3 of 5Hickory Creek At CrawfordsvilleCrawfordsville, IN 3 of 5Hillcrest VillageJeffersonville, IN 3 of 5North Capitol Nursing & Rehabilitation CenterIndianapolis, IN 3 of 5Rosebud VillageRichmond, IN 3 of 5Rosewalk VillageIndianapolis, IN 3 of 5Rosewalk Village At LafayetteLafayette, IN 3 of 5Spring Mill MeadowsIndianapolis, IN 3 of 5Stonebrooke Rehabilitation CenterNew Castle, IN 4 of 5Autumn Ridge Rehabilitation CentreWabash, IN 4 of 5Beech Grove MeadowsBeech Grove, IN 4 of 5Clark Rehabilitation And Skilled Nursing CenterClarksville, IN 4 of 5Clinton GardensClinton, IN 4 of 5Creekside VillageMishawaka, IN 4 of 5Edgewater WoodsAnderson, IN 4 of 5Forest Creek VillageIndianapolis, IN 4 of 5Franklin MeadowsFranklin, IN 4 of 5Heritage House Rehabilitation & Health Care CenterConnersville, IN 4 of 5Hickory Creek At ColumbusColumbus, IN 4 of 5Hickory Creek At MadisonMadison, IN 4 of 5Hickory Creek At PeruPeru, IN

Showing 40 of 89; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
DRUMMER, CARLIndividualCORPORATE DIRECTORsince 01/01/2017
HANIFY, THOMASIndividualCORPORATE DIRECTORsince 01/01/2022
HORN, BRENDAIndividualCORPORATE DIRECTORsince 12/01/2023
LAZARD, ROBERTIndividualCORPORATE DIRECTORsince 01/29/2021
MANTRAVADI, GEETAIndividualCORPORATE DIRECTORsince 07/21/2021
PAYNE, MONICAIndividualCORPORATE DIRECTORsince 08/09/2021
BABCOCK, PAULIndividualCORPORATE OFFICERsince 09/30/2020
CAINE, VIRGINIAIndividualCORPORATE OFFICERsince 01/10/1994
HARRIS, LISAIndividualCORPORATE OFFICERsince 12/22/2003
AMERICAN SENIOR COMMUNITIES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2009
BRANNING, MORGANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/19/2024
DICE, MARKIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2023
VAN CAMP, STEVENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2023
VOLKMAN, SARAHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2023
ZILIAK, SARAHIndividualOPERATIONAL/MANAGERIAL CONTROLsince 07/29/2024

CMS files one row per role, so the 20 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$10.1M
Net patient revenuemost recent cost report
+4.7%
Operating marginrevenue minus expenses
$933K
Related-party expense10% of expenses
Who pays — share of resident-days
Medicaid 79%Medicare 4%Other / private 17%

About 79% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $933K 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

$293per resident / day
operating cost
$8,918per month
≈ monthly operating cost
$308per day
avg. revenue, all payers

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

What families pay in IN

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 155148. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-21, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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