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Parkview Care Center

2819 North St Joseph Ave, Evansville, IN 47720 · For profit - Corporation · 99 certified beds · (812) 424-2941 Medicare & Medicaid certified

Call the home — (812) 424-2941 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 27 lower-level deficiencies on record (see below)
Insights

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

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • about 73% 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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 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 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2925 N Saint Joseph Ave · (812) 425-8042 · Call to confirm hours
Pharmacy
Walgreens1.4 mi
710 N Saint Joseph Ave · (812) 426-1180 · Call to confirm hours
Grocery
cindy1467<0.1 mi
2819 N Saint Joseph Ave
Park
2421 Bement Ave · (270) 577-5903 · 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
Short-stay residentsrehab / post-hospital 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 held steady at 3 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 rating3★
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 increased6.0%11.0%15.4%better
Long-stay residents who lose too much weight1.2%5.5%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%1.1%2.0%better
Long-stay residents with depressive symptoms6.8%25.2%6.5%typical
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 injury0.4%3.9%3.3%better
Long-stay residents whose ability to walk worsened13.6%11.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication21.2%23.5%18.9%worse
Long-stay residents given the seasonal flu vaccine81.0%95.4%95.3%worse
Long-stay residents with pressure ulcers3.4%3.6%4.7%better
Long-stay residents with worsening bladder/bowel control24.0%23.3%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table6.8%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 vaccine23.2%79.0%79.4%worse
Short-stay residents rehospitalized after admission24.8%22.2%22.6%typical
Short-stay residents with an outpatient ER visit6.6%10.8%12.0%better
Long-stay hospitalizations per 1,000 resident days1.821.611.67typical
Long-stay outpatient ER visits per 1,000 resident days1.531.441.80better

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.

53.6% 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 35 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

53.6%U.S. median 51.5%
Got home and stayed home
8.8%U.S. median 10.7%
Went back to hospital
87.9%U.S. median 56.6%
Met the expected recovery
0.33U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 87.9% 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 33 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 0.33 therapist hours per resident per day in 2026Q1 — more than 54% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF53.6%CMS range 40.8–66.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.8%CMS range 5.5–12.510.7%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 discharge87.9%56.6%Oct 2024–Sep 2025CMS 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 discharge66.7%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge81.8%50.0%Oct 2024–Sep 2025CMS 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 identified90.5%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 hospitalization6.8%CMS range 3.6–14.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.241.02Oct 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

0.66
RN hours/ resident / day
0.65
LPN hours/ resident / day
2.29
Aide hours/ resident / day
3.60
Total nurse hours/ resident / day
0.37
RN hoursweekends
40.2%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 99 beds and averages 80.8 residents a day — about 82% 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 3.60 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.66 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.29 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.25 hrs/resident/day on weekends vs 3.74 on weekdays — 13% thinner on weekends. RN hours go from 0.77 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

9
deficiencies at the latest standard inspection (2025-12-11)
9
at the previous standard inspection (2024-09-26)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.

  • Potential for harm · F2025-12-11 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure the kitchen manager met required qualifications for 1 of 1 dietary manager qualifications reviewed. 80 of 82 residents in the facility received nutrition provided by facility dietary.Finding includes: During an interview on 12/8/25 8:45 A.M., the dietary manager indicated she did not have a dietary manager certification. On 12/11/25 at 8:25 A.M., the dietary manager's employee file was reviewed; the employee file indicated the dietary manager had been employed since 10/15/14 and had enrolled to take the dietary manager training 8/20/24, but had not yet taken it. During an interview on 12/8/25 at 8:45 A.M., the dietary manager indicated the dietician worked through a contract and was only not in the facility full time. On 12/11/25 at 1:50 P.M., the Administrator provided a policy titled Departmental Leadership Requirements, revised 4/16/24, that indicated If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as 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
  • Potential for harm · E2025-12-11 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure food was prepared to meet the individual needs of residents receiving puree diet for 1 of 3 observation of puree foods. Finding includes: During an interview on 12/10/25 at 11:02 A.M., the dietary manager indicated there were four residents who received puree diet, and one resident received double puree portions. During an observation on 12/10/25 at 11:04 A.M., dietary staff prepared puree zucchini, puree noodles, and puree beef. The beef was not of puree consistency and was dry, thick, with lumps. During an interview on 12/10/25 at 11:14 A.M., the dietary manager indicated puree consistency should be similar to applesauce. During an observation on 12/10/25 at 11:50 A.M., dietary was checking the temperature of the foods served on the steam table. The dietary manager indicated the puree beef was not the appropriate consistency; she added two cups of beef broth to the puree beef and placed in back in the serving dish. The beef was not of puree consistency and was thick with lumps. On 12/11/25 at 1:53…

    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 · D2025-12-11 · 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 that residents who were self-administering medications were assessed for capability to self-administer medications for 1 of 1 residents with medications observed in their room. (Resident 2)Finding includes:On 12/9/25 at 9:31 A.M., Resident 2 was observed in bed with a bottle of Nystatin, dated 1/2/25, on her bedside table. At that time, Resident 2 indicated that she used the Nystatin as needed to treat thrush (a yeast infection) in her mouth. On 12/9/25 at 11:22 A.M., Resident 2's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, schizophrenia, and diabetes mellitus. The most current Annual Minimum Data Set (MDS) Assessment, dated 11/20/25, indicated that Resident 2 had mild cognitive impairment, was independent in eating and transferring, required setup assistance of staff for toileting and bathing, and did not have any infections.Discontinued physician orders included, but were not limited to:Nystatin Mouth/Throat Suspension (a medication used to treat fungal…

    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 before2025-12-11 · 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 ensure the development of a resident's comprehensive care plan for 1 of 1 residents reviewed for Respiratory Care and 1 of 5 residents reviewed for medications. (Resident 11, Resident 33)Findings include: 1. On 12/09/25 at 10:44 A, M., Resident 33's clinical record was reviewed. Diagnoses included, but were not limited to type 2 diabetes mellitus, unspecified, thoracic, thoracolumbar and lumbosacral intervertebral disc disorder, and atrial fibrillation. The current admission Minimum Data Set (MDS) Assessment indicated Resident 33 was cognitively intact. Resident 33 required partial to moderate assistance with toileting and dressing, and supervision with transferring. During the 7 day look back period the resident did not require oxygen therapy. Current physician orders included, but were not limited to:Oxygen at 2 liters/minute per nasal cannula as needed for SPO2 <90% as needed dated 10/31/25.Change oxygen tubing, humidifier bottle, and nebulizer circuit weekly every night shift every Sun Label when changed…

    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 · D2025-12-11 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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 physician orders were followed and obtained a residents daily weight for 1 of 1 residents reviewed for hospitalizations. (Resident 81) Finding includes: On 12/9/25 at 10:51 A.M., Resident 81's clinical record was reviewed. Resident 81 was admitted on [DATE]. Diagnoses included, but were not limited to, heart failure. The most recent admission Minimum Data Set (MDS) Assessment, dated 10/24/25, indicated Resident 81 was cognitively intact, required substantial assistance (staff do more than half of the work) for toileting, and received diuretic medication. Physician orders included, but were not limited to: Daily weight for 60 days: Notify MD/NP if greater than three pound gain in 24 hours or greater than five pound gain in seven days. Weight to be obtained is dry weight at 0700; Follow medication instructions for (as needed) Bumetanide 1 MG in the morning related to congestive heart failure for 60 days; Start date 11/12/25Bumetanide Oral Tablet 1…

    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 before2025-12-11 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper oxygen services were provided according to physician orders for 1 of 1 residents reviewed for respiratory care. (Resident 33) Findings include: On 12/9/25 at 10:02 A.M., Resident 33 was observed sitting in a wheelchair wearing oxygen (O2) at 2 Liters/Nasal Cannula connected to a concentrator. The concentrator had a humidification bottle attached with no water present. On 12/10/25 at 9:40 A.M., Resident 33 was out of the room and the O2 concentrator was observed with the humidification with no water present. On 12/09/25 at 10:44 A, M., Resident 33's clinical record was reviewed. Diagnoses included, but were not limited to type 2 diabetes mellitus, unspecified, thoracic, thoracolumbar and lumbosacral intervertebral disc disorder, and atrial fibrillation. The current admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident 33 was cognitively intact. Resident 33 required partial to moderate assistance with…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-11 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure it was free of a medication error rate of greater than 5 percent for 2 of 7 residents (Resident 28 and Resident 75) observed during the medication pass. There were 25 opportunities observed with 2 errors, resulting in an 8 percent medication error rate. Findings include:1. On 12/11/25 at 7:56 A.M., Registered Nurse (RN) 3 was observed preparing a Basaglar Kwikpen for insulin administration for Resident 28. RN 3 indicated that Resident 28 had a standing order for 40 units of insulin two times a day. RN 3 set the pen to 40 units, attached the needle, and administered the insulin to Resident 28 in her abdomen. RN 3 did not prime the insulin pen prior to administration. During an interview on 12/11/25 at 8:00 A.M., RN 3 indicated that the pen was supposed to be primed with one or two units of insulin prior to setting the dosage. On 12/11/25 at 9:15 A.M., Resident 28's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus. The most current Annual Minimum Data Set (MDS)…

    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 · Dcited before2025-12-11 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control practices and standards were followed in 1 of 1 residents observed for catheter care. (Resident 6) Hand hygiene was not performed correctly.Finding includes: On 12/10/25 at 9:03 A.M., Certified Nurse Aide (CNA) 7 and CNA 9 were observed performing catheter care for Resident 6. Prior to donning gown and gloves, CNA 9 washed her hands for eight seconds. After performing the care and prior to emptying the catheter bag, CNA 9 washed her hands for 12 seconds. After all care was completed and prior to leaving the room, CNA 9 washed her hands for seven seconds and CNA 7 washed her hands for 13 seconds. During an interview on 12/11/25 at 7:35 A.M., the Infection Preventionist (IP) indicated that staff were trained to wash their hands for at least 40 seconds, but preferably 60 seconds. On 12/11/25 at 12:50 P.M., the Administrator provided a current Hand Hygiene policy, revised 10/28/25, that indicated This facility will…

    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 · D2025-12-11 · tag F0940 — failed to train staff — isolated
    Develop, implement, and/or maintain an effective training program for all new and existing staff members.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that the staff was adequately trained to use an external catheter device for 1 of 1 residents observed with external urinary catheter. (Resident 1) Findings include:On 12/9/25 at 11:33 A.M., Resident 1's clinical record was reviewed. Diagnoses included, but were not limited to, unspecified urinary incontinence, muscle weakness, and malignant neoplasm of the ascending colon The current admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident 1 was cognitively intact. Resident 1 required substantial maximum assistance for toileting, hygiene, and transferring and utilizing an external catheter appliance at night. Current Physician Orders included, but were not limited to:External catheter appliance urine collection system - Ensure system is level with the height of the bed when on every shift related to UNSPECIFIED URINARY INCONTINENCE dated 11/14/25.External catheter appliance to cannister drainage for diagnosis of Urinary…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-19 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, on 3 of 3 units reviewed. The resident rooms had urine odors, damaged and unclean flooring. (Unit 100, Unit 200, Unit 300) Finding includes : The following was observed between 8:42 a.m. to 9:35 a.m. : room [ROOM NUMBER]- A strong urine odor in the bathroom. The same was observed at 1:17 p.m.room [ROOM NUMBER] - A strong urine odor in the bathroom. The same was observed at 1:19 p.m.Bathroom shared with room [ROOM NUMBER] and 207- Caulking around the wall was crumbling, and debris on the floor.Bathroom shared with room [ROOM NUMBER] and 210- Debris and cobwebs around wall edges, missing flooring. Bathroom shared with room [ROOM NUMBER] and 211- debris around wall edges, crumbling caulking.Bathroom shared with room [ROOM NUMBER] and 214 - debris around edges of wall and cobwebs.Bathroom shared with room [ROOM NUMBER] and 215- holes in linoleum flooring.room…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · D2025-03-07 · 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 wound care for 2 of 3 residents reviewed for wounds. (Resident B, Resident C) Findings include: 1. On 3/6/25 at 9:44 a.m., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, displaced intertrochanter fracture of left femur, subsequent encounter for closed fracture with routine healing, other injury of unknown body region, subsequent encounter. An admission Minimum Data Set (MDS) assessment dated [DATE], indicated cognition was intact, 1 stage two pressure ulcer on admit. Resident B admitted to the facility on [DATE], discharged on 2/10/25. Care plans included, but were not limited to: Enhanced barrier precautions r/t (related to) impaired skin integrity. Interventions included, but were not limited to: weekly skin checks, Tx (treatment) as ordered, date initiated 1/22/25, revision on 2/28/25. At risk for break in skin integrity. Resident refuses use 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-09-26 · tag F0656 — failed to write and follow a full care plan — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop care plans for 2 of 3 residents reviewed for Urinary Tract Infections (UTI), 1 of 1 residents reviewed for tube feedings, 2 of 5 residents reviewed for unnecessary medications, and 1 of 1 residents reviewed for hospice services. A care plan was not developed for residents receiving high risk medications, timeliness of tube feedings, for residents requiring assistance with transferring, and after residents received a new diagnosis and new medication orders. (Resident C, Resident N, Resident L, Resident Z, Resident J, Resident V) Findings include: 1. On 9/23/24 at 8:32 A.M., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, Urinary Tract Infection. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 6/19/24, indicated Resident C was not assessed for cognitive impairment due to rarely or never being understood, required substantial to maximal assistance of staff (staff does more than half) 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-09-26 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    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, observation, and record review, the facility failed to ensure residents requiring assistance with Activities of Daily Living (ADLs) were bathed or assisted to bathe for 5 of 7 residents reviewed for ADL care. (Resident V, Resident P, Resident S, Resident T, Resident C) Findings include: 1. On 9/23/24 at 8:20 A.M., Resident V's clinical record was reviewed. Resident V was admitted on [DATE]. Diagnoses included, but were not limited to, spinal muscular atrophy and scoliosis. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 6/17/24, indicated Resident was cognitively intact and was completely dependant on staff (staff does all of the effort) for bathing, toileting, and mobility. Current care plans included, but were not limited to: Resident request a Complete Bed Bath one time a week and often refuses. Date Initiated: 4/27/24 During an interview on 9/24/24 at 2:40 P.M., Resident V indicated she would like to receive a complete bed bath more than once a week, but staff told her…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-09-26 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure proper storage of medications for 4 of 6 medication carts. Loose pills were observed in the medication cart drawers. (Cherry Lane Medication Cart, Dogwood Lane Cart 1, [NAME] Lane Cart 1, [NAME] Lane Cart 2) Findings include: On 9/19/24 at 9:00 A.M., the Cherry Lane Medication Cart was observed with the following loose pills and materials: 1 small, oblong, white, pill Broken pieces of peach pill 1 small, round, white, pill 1 bottle of water in lower drawer On 9/19/24 at 9:05 A.M., the Dog [NAME] 1 Medication Cart was observed with the following loose pills: 1 small round pink pill with # 50 1 white capsule with #IP 101 1 long, oblong, white pill TGL #341 1/2 small, round, white pill 1 small, round, white pills 1/2 small, oblong, pink pill On 9/19/24 at 9:18 A.M., the [NAME] Lane 1 Medication Cart was observed with the following loose pills: 2 ½ small, round, white pills 1/2 small, round, brown pill On 9/19/24 at 9:25 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-26 · 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

    Based on interview and record review, the facility failed to notify the physician and resident representative of changes in a resident's medical status for 1 of 1 residents reviewed for skin conditions and urinary tract infections. The physician was not notified of a new wound, and the resident's representative was not notified of a new wound, new diagnosis, and new medication order. (Resident C) Finding includes: On 9/20/24 at 10:20 A.M., a family member indicated that on 9/18/24 they found a dressing covering a wound on Resident C's foot. Upon further inspection, sores were found on his buttocks, on the back of his thigh, on his scrotum, and on his perineum. They requested a skin assessment be completed that day with the wound nurse to show her Resident C's skin injuries. They indicated they believed that Resident C had a UTI, but lab work had not returned and the resident had not been started on antibiotics yet. In a confidential interview on 9/20/24 at 12:38 P.M., it was indicated that a staff member had put bandages on Resident C's foot without letting anyone know he had sores.…

    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 · D2024-09-26 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and observation, the facility failed to ensure residents with limited range of motion received restorative nursing services to further prevent decrease in range of motion for 2 of 4 residents reviewed for ADL (activities of daily living) care who receive restorative nursing. (Resident V, Resident 35) Findings include: 1. During an interview on 9/19/24 at 2:14 Resident V indicated she had not received restorative nursing any days that week. Resident V had contractures of all extremities. On 9/23/24 at 8:20 A.M., Resident V's clinical record was reviewed. Resident V was admitted on [DATE]. Diagnoses included, but were not limited to, spinal muscular atrophy and scoliosis. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 6/17/24, indicated Resident was cognitively intact and was completely dependant on staff (staff does all of the effort) for bathing, toileting, and mobility. Current care plans included, but were not limited to: Resident has impaired mobility due…

    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 before2024-09-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview the facility failed to ensure an oxygen concentrator filter was being cleaned for 1 of 1 resident reviewed for respiratory care (Resident P). Finding includes: On 9/23/24 at 10:17 A.M., Resident P's oxygen concentrator was observed to have moderate dust on the filter cover. On 9/23/24 at 10:30 A.M. Resident P's clinical record was reviewed and indicated the resident had diagnoses that included but was not limited to COPD (chronic obstructive pulmonary disease). A Quarterly MDS (Minimum Data Set) Assessment on 9/23/24 indicated Resident was cognitively intact and required the use of oxygen. Resident P had a current physician order for oxygen at three liters, continuously per nasal cannula, dated 5/4/24. On 9/25/24 at 10:41 A.M. DON (Director of Nursing) indicated that nurses were responsible for cleaning filters on oxygen concentrators every Sunday and it was expected to be a task in a resident's Treatment Administration Record. Resident P's clinical record lacked an order for the Treatment Administration Record to clean the filter…

    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 · D2024-09-26 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the documentation was completed and accurate for 2 of 2 residents reviewed for accuracy of falls documentation. (Resident P and Resident 12) Findings include: 1. On 9/23/24 at 10:30 A.M. Resident P's clinical record was reviewed and indicated the resident had diagnoses that included but was not limited to diabetes mellitus and COPD (chronic obstructive pulmonary disease). A Quarterly MDS (Minimum Data Set) Assessment on 9/23/24 indicated Resident was cognitively intact, had no behaviors, and used a wheelchair. A state optional MDS dated [DATE], indicated Resident was independent in bed mobility and toileting, required supervision with transfers, and the resident was on a pain medication regimen with occasional pain that affected day to day activities. A progress note in Resident P's clinical record, dated 9/18/24 at 3:54 A.M., indicated the resident was found laying on the floor, face down, in her room. Indicated that it was believed Resident P…

    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 · D2024-09-26 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    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 communication process with hospice personnel was developed and implemented, including how the communication will be documented between the LTC (long term care) facility and the hospice provider, and to ensure that the needs of the resident were addressed. The clinical record lacked documentation of ongoing communication between facility staff and hospice staff for 1 of 1 residents reviewed for hospice. (Resident J) Finding includes: On 9/25/24 at 2:09 P.M. Resident J's clinical record was reviewed and indicated that Resident had diagnoses that included but was not limited to heart failure and atrial fibrillation. A significant change MDS (Minimum Data Set) assessment dated [DATE] indicated that the resident was cognitively intact and receiving hospice care. Physician Orders included but were not limited to: Admit to (Name of Hospice Company), dated 6/15/24. Resident J's clinical record lacked a care plan related to hospice services. Resident…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-03 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control practices were maintained to mitigate the spread of COVID-19 for 3 of 4 observations. Staff were observed to enter COVID- 19 positive resident rooms without the proper PPE or correct donning of PPE (Personal Protective Equipment). ( room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER],) Findings included: On 1/2/24 at 8:39 a.m., LPN 1 was observed to have on an N95 mask, don a gown, gloves, face shield and enter room [ROOM NUMBER]. LPN 1 did not fasten the gown at the neck. room [ROOM NUMBER] had an isolation sign on the door and a sign with instructions on how to don and doff PPE (Personal Protective Equipment), including, but not limited to .put on isolation gown. Tie all of the ties on the gown. Assistance may be needed by another HCP (healthcare professional) . room [ROOM NUMBER] was in isolation for Covid- 19. On 1/2/24 at 8:40 a.m., CNA 1 was observed to have on an N95 mask, don a gown, 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-06-26 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    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 MDS (minimum data set) Assessments were accurate for 2 of 6 residents reviewed for unnecessary medications, 1 of 2 residents reviewed for dental, and 1 of 1 residents reviewed for pressure ulcers. (Resident 1, Resident 18, Resident 58, Resident 62) Findings include: 1. On 6/20/23 at 1:44 P.M., Resident 1's clinical record was reviewed. Diagnosis included, but were not limited to, anxiety, depression, bipolar disorder, and psychotic disorder. The most recent quarterly MDS Assessment, dated 5/12/23, indicated no cognitive impairment. The MDS assessment indicated Resident 1 had not received an anticoagulant, diuretics, or opioids during the 7 day look back period. Current physician orders included, but were not limited to, the following: Fentanyl Patch (an opioid) 75mcg/hour (micrograms per hour) every 72 hours for pain, dated 2/18/23. furosemide (a diuretic) 40mg daily, dated 12/12/22. rivaroxaban (an anticoagulant) 20mg daily, dated…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-06-26 · tag F0657 — failed to keep the care plan current — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure care plan conferences were completed and care plans revised for 2 of 5 residents reviewed for Accidents, 1 of 2 residents reviewed for Care Planning, 1 of 2 residents reviewed for Dental, and 1 of 2 residents reviewed for Respiratory Care. (Resident 1, Resident 22, Resident 34, Resident 51, and Resident 62) Findings include: 1. On 6/20/23 at 9:22 A.M., Resident 34 was observed to be on 4 L (liters) oxygen with humidification via nasal cannula. The date on the tubing was 6/12 and the date on the humidification bottle was 6/19. On 6/20/23 at 2:20 P.M., Resident 34's clinical record was reviewed. Resident 34 was admitted on [DATE]. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, morbid obesity, congestive heart failure, and dependence on supplemental oxygen. The most recent admission MDS (Minimum Data Set) assessment, dated 5/2/23, indicated Resident 34 was cognitively intact and was on oxygen.…

    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 · D2023-06-26 · tag F0638 — isolated
    Assure that each resident’s assessment is updated at least once every 3 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a quarterly assessment Minimum Data Set (MDS) assessment was completed timely for 3 of 16 residents reviewed. (Residents 60, Resident 22, Resident 3) Findings include: 1. Resident 60's record was reviewed on 6/20/23 at 1:29 P.M. The resident was admitted on [DATE]. The admission MDS assessment was dated 2/28/23 as completed. The clinical record lacked a completed MDS assessment following that date. 2. On 6/22/23 at 8:14 A.M., Resident 22's clinical record was reviewed. Resident 22 was admitted on [DATE]. The most recent completed quarterly MDS (Minimum Data Set) assessment was dated 3/3/23. The clinical record lacked a completed MDS assessment after that date. During an interview on 06/26/23 at 10:20 A.M., the MDS Coordinator indicated that quarterly MDS assessments were due every 90 days. He further indicated that the facility was behind on getting MDS assessments completed and submitted. 3. On 6/26/23 at 10:03 A.M., Resident 3's clinical…

    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 before2023-06-26 · 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 ensure physician orders and care plan interventions were followed for 1 of 1 residents reviewed for activities of daily living, and 1 of 1 residents reviewed for mobility. (Resident 23, Resident 62) Findings include: 1. On 6/19/23 at 9:32 A.M., Resident 23 was observed lying in bed with the right hand drawn up and contracted. No appliance (splint/brace) was observed on the right hand. On 6/21/23 at 9:33 A.M., Resident 23 was observed lying in bed with the right hand drawn up and contracted. No appliance (splint/brace) was observed on the right hand. On 6/20/23 at 1:47 P.M., Resident 23's clinical record was reviewed. Diagnosis included, but were not limited to depression and psychotic disorder. The most recent quarterly MDS Assessment, dated 3/12/23, indicated Resident 23 was cognitively intact, and required extensive assistance of one staff for bed mobility and toileting, and was totally dependent of one staff for bathing. The MDS indicated no restorative services, and no splint or brace assistance. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-26 · 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 observation, interview, and record review, the facility failed to ensure services were provided to maintain personal hygiene for 2 of 3 residents reviewed for activities of daily living. Dependent residents were not provided showers as scheduled or according to preference. (Resident 1, Resident 62) Findings include: 1. On 6/19/23 at 10:18 A.M., Resident 1 indicated her hair was not getting washed because the staff could not accommodate her preference for having her hair washed. She indicated she had requested that staff wash her hair in bed with the water running into a trash can, and was told that could not happen as the trash can would be too heavy for staff to pick up and empty. She indicated she was supposed to be bathed twice a week, and was not getting them that often. On 6/20/23 at 1:44 P.M., Resident 1's clinical record was reviewed. Diagnosis included, but were not limited to, anxiety, depression, bipolar disorder, and psychotic disorder. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · Ccited before2024-09-26 · 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 6 days during the annual survey period. Finding includes: During an observation on 9/23/24 at 2:59 P.M., a posted nurse staffing data sheet, dated 9/23/24, was observed on the nurses station desk inside the main entrance. 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), QMA (Qualified Medication Aide) and RN (Registered Nurse). The sheet indicated that 2 LPNs worked 20 hours between 7:00 A.M. and 7:00 P.M. but did not specify the actual hours that the staff worked. The sheet indicated that 1 QMA worked 8 hours between 7:00 A.M. and 7:00 P.M. but did not specify the actual hours that the staff worked. The sheet indicated that 1 QMA worked 4 hours between 7:00 P.M. and 7:00 A.M. but did not specify the actual hours…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • No harm found · Ccited before2023-06-26 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the daily posted nurse staffing reflected the actual hours worked by staff for 3 of 6 days during the survey. Findings include: During an observation on 6/19/23 at 10:30 A.M., the posted daily staffing sheet included the date, census, RN (Registered Nurse), LPN (Licensed Practical Nurse), and CNA (Certified Nurse Aide) columns with number present and total hours worked for days, evenings, and nights. The sheet did not indicate the time frame of the different shifts and lacked actual hours worked by staff. On 6/21/23 at 9:20 A.M., the posted daily staffing sheet lacked actual hours worked by staff. On 6/24/23 at 9:18 A.M., the posted daily staffing sheet lacked actual hours worked by staff. On 6/26/23 at 9:00 A.M., The Director of Nursing and Administrator indicated they were unaware that the posted daily staffing sheets were required to have actual hours indicated on them, and that it was assumed visitors would know what hours days, evenings, and nights were. On 6/26/23 at 9:09 A.M., a current Staffing…

    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

No federal fines in the current CMS record.

Part of a chain

This home belongs to LIFE CARE CENTERS OF AMERICA — 194 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 53.4-0.4 vs chain
Health inspection 2 of 52.8-0.8 vs chain
Staffing 3 of 53.3-0.3 vs chain
Quality measures 5 of 54.5+0.5 vs chain
The other 193 homes this chain runs (chain average 3.4★, per CMS)
1 of 5Garden Terrace At Overland ParkOverland Park, KS 1 of 5Hammond-Whiting Care CenterWhiting, IN 1 of 5Life Care Center Of AndoverAndover, KS 1 of 5Life Care Center Of Cape GirardeauCape Girardeau, MO 1 of 5Life Care Center Of GrayGray, TN 1 of 5Life Care Center Of HixsonHixson, TN 1 of 5Life Care Center Of Mount VernonMount Vernon, WA 1 of 5Life Care Center Of RenoReno, NV 1 of 5Life Care Center Of Sierra VistaSierra Vista, AZ 1 of 5Life Care Center Of The WillowsValparaiso, IN 1 of 5Life Care Center Of TucsonTucson, AZ 1 of 5Life Care Center of Coeur d'AleneCoeur d'Alene, ID 1 of 5Life Care Center of ElkhornElkhorn, NE 1 of 5Life Care Center of Hilton HeadHilton Head Island, SC 1 of 5Life Care Center of OmahaOmaha, NE 1 of 5Life Care Center of PlainwellPlainwell, MI 1 of 5Life Care Ctr Of LawrencevilleLawrenceville, GA 1 of 5Rensselaer Care CenterRensselaer, IN 2 of 5Canon Lodge Care CenterCanon City, CO 2 of 5Darcy Hall Of Life CareWest Palm Beach, FL 2 of 5Desert Cove Nursing CenterChandler, AZ 2 of 5Evergreen Nursing HomeAlamosa, CO 2 of 5Garden Terrace Healthcare Center of HoustonHouston, TX 2 of 5Hallmark ManorFederal Way, WA 2 of 5Lane House, TheCrawfordsville, IN 2 of 5Life Care Center Of Altamonte SpringsAltamonte Springs, FL 2 of 5Life Care Center Of AthensAthens, TN 2 of 5Life Care Center Of BridgetonBridgeton, MO 2 of 5Life Care Center Of BrookfieldBrookfield, MO 2 of 5Life Care Center Of ClevelandCleveland, TN 2 of 5Life Care Center Of ColumbiaColumbia, SC 2 of 5Life Care Center Of Coos BayCoos Bay, OR 2 of 5Life Care Center Of Federal WayFederal Way, WA 2 of 5Life Care Center Of GrandviewGrandview, MO 2 of 5Life Care Center Of KirklandKirkland, WA 2 of 5Life Care Center Of Merrimack ValleyBillerica, MA 2 of 5Life Care Center Of Morgan CountyWartburg, TN 2 of 5Life Care Center Of PuyallupPuyallup, WA 2 of 5Life Care Center Of Red BankChattanooga, TN 2 of 5Life Care Center Of South Las VegasLas Vegas, NV

Showing 40 of 193; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleSince
ENGELS, ERINIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 10/01/2018
GENTRY, MARKIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 01/12/2022
STARKEY, TYLERIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 08/01/2020
WAITE, JOHNIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 08/01/2020
WHICKER, TIMOTHYIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 01/12/2022
FENOUGHTY, DEANNAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 07/10/2023
CONSOLIDATED RESOURCES HEALTH CARE FUND I LPOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2018
LIFE CARE CENTERS OF AMERICA, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/13/2025
FLETCHER, TODDIndividualOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2018
HENRY, TERRYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2018
JONES, TAMELAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/20/2024
LAY, LISAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2018
PRESTON, AUBREYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2018
SWANKER, RICHARDIndividualOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2018
THURMOND, JOANIndividualOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2018
VOLKMAN, SARAHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
ZIEGLER, JAMESIndividualOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2018
HENDRICKS COUNTY HOSPITALOrganizationADP OF THE SNFsince 02/24/2025
PRESTON, FORRESTIndividualADP OF THE SNFsince 10/01/2018

CMS files one row per role, so the 29 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

$8.9M
Net patient revenuemost recent cost report
+3.6%
Operating marginrevenue minus expenses
$6.3M
Related-party expense73% of expenses
Who pays — share of resident-days
Medicaid 64%Medicare 13%Other / private 23%

This home reported $6.3M paid to related parties — landlords or management companies under common ownership — equal to about 73% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$358per resident / day
operating cost
$10,890per month
≈ monthly operating cost
$371per 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 155348. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-11, 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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