No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Hamilton Trace Of Fishers

11851 Cumberland Rd, Fishers, IN 46037 · For profit - Corporation · 108 certified beds · (317) 813-4444 Medicare & Medicaid certified

Call the home — (317) 813-4444 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0607) — cited Nov 2022
Insights

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

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • about 31% 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) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 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, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
FAIRBANKS4.6 mi
 
Urgent care / clinic
Fishers0.2 mi
11580 Overlook Dr., Suite 100
Pharmacy
11900 Exit Five Pkwy · (317) 889-4125 · Call to confirm hours
Grocery
9774 EAST 116TH STREET
Place of worship
POSTAL ANNEX+, 9783 E 116th St · (317) 250-5108

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 fell from 4 to 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 increased15.0%11.0%15.4%typical
Long-stay residents who lose too much weight6.6%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 infection0.4%1.1%2.0%better
Long-stay residents with depressive symptoms3.0%25.2%6.5%better than 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 injury5.5%3.9%3.3%worse
Long-stay residents whose ability to walk worsened7.6%11.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication28.9%23.5%18.9%worse
Long-stay residents given the seasonal flu vaccine98.7%95.4%95.3%typical
Long-stay residents with pressure ulcers3.0%3.6%4.7%better
Long-stay residents with worsening bladder/bowel control20.4%23.3%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table5.3%13.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.2%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine89.9%79.0%79.4%better
Short-stay residents rehospitalized after admission17.0%22.2%22.6%better
Short-stay residents with an outpatient ER visit11.2%10.8%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.271.611.67better
Long-stay outpatient ER visits per 1,000 resident days0.861.441.80better

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.

64.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 445 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

64.0%U.S. median 51.5%
Got home and stayed home
13.1%U.S. median 10.7%
Went back to hospital
47.8%U.S. median 56.6%
Met the expected recovery
0.72U.S. median 0.31
Therapy hours / resident / day
0.27hours / resident / day
Physical therapy
0.33hours / resident / day
Occupational therapy
0.12hours / resident / day
Speech therapy

Met the expected recovery: 47.8% 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 159 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 0.72 therapist hours per resident per day in 2026Q1 — more than 92% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 22% 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 SNF64.0%CMS range 58.2–67.951.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF13.1%CMS range 10.4–16.110.7%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 discharge47.8%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 discharge52.2%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 discharge35.2%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 identified45.1%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 setting90.2%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge91.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF 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 worsened1.5%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 hospitalization5.2%CMS range 3.3–8.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.861.02Oct 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

0.73
RN hours/ resident / day
1.32
LPN hours/ resident / day
1.69
Aide hours/ resident / day
3.74
Total nurse hours/ resident / day
0.39
RN hoursweekends
36.2%
Total nursing turnover
27.8%
RN turnover

How full it usually is: this home is certified for 108 beds and averages 102.6 residents a day — about 95% occupied, or roughly 5 beds typically open. It runs essentially full — expect a waiting list. 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 3.74 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.73 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.69 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 3.20 hrs/resident/day on weekends vs 3.96 on weekdays — 19% thinner on weekends. RN hours go from 0.87 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 36% 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

13
deficiencies at the latest standard inspection (2025-05-12)
4
at the previous standard inspection (2024-03-08)

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

Inspection deficiencies

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

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.

25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.

  • Potential for harm · Dcited before2026-02-10 · 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 follow their policies and procedures for infection control, related to hand hygiene during dressing changes for 1 of 3 residents reviewed for infection control. (Resident D) Findings include: During an observation of wound care for Resident D, on 2-10-26 at 10:55 a.m., RN 3 and the Wound Care Nurse explained the procedure they were going to provide to the resident. The resident was to have the staff follow Enhanced Barrier Precautions (EBP- infection control measures for nursing homes, requiring staff to wear gowns and gloves during high-contact care for residents with chronic wounds to prevent germ spread, even when standard contact) for wound care. The RN and Wound Care Nurse removed the resident's wound dressing from the resident's right lower extremity (RLE). Gloves were removed and discarded with new gloves applied without hand hygiene or handwashing being observed. After the treatment to the resident's RLE wound area, both nurses assisted in cleaning up the area. Gloves were removed and discarded 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-30 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a resident with a urinary catheter was provided with catheter care, monitoring, and documenting of urine outputs for 1 of 3 residents reviewed for catheters. (Resident B) Findings include: The clinical record for Resident B was reviewed on 1/30/24 at 2:00 p.m. The diagnoses for Resident B included, but were not limited to, central cord syndrome (spinal cord injury causing weakness without being paralyzed.) and neuromuscular dysfunction of bladder (loss of bladder control). A physician's order, dated 12/20/25, indicated the staff were to bladder scan Resident B for urine retention every shift. If the resident's urine totals in the bladder were greater than 200 milliliters the medical provider was to be contacted. A physician's order, dated 12/29/25, indicated the staff was to remove Resident B's urinary catheter. The January 2026 Medication/Treatment Record (MAR/TAR) indicated on 12/20/25 in the evening shift, the resident's urine residual in his bladder was 855 milliliters. A physician's note, dated 12/20/25,…

    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 · F2025-05-12 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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 the use of beard restraints by dietary staff, separate storage of a personal lunch bag, ensure coverage of stored frozen food and ready-to-eat dessert, and distribution of food under sanitary conditions. This had the potential to affect 96 of 96 residents in the facility. Findings include: A kitchen tour was conducted, on 5/5/25 at 9:30 a.m., with the [NAME] Supervisor (CS). Dietary Aide (DA) 9 was observed in the kitchen without the use of a beard restraint to cover his facial hair and instead was wearing a surgical mask below his chin. An observation of the walk-in freezer was made during the tour. Four bowls of uncovered chocolate ice cream were observed on a tray. A personal lunch bag was observed sitting on a rack within the freezer. An observation of the main dining room was conducted on 5/5/25 at 12:24 p.m. Plates of dessert cakes were observed uncovered sitting on a cart, partially stacked on top of one another. During an interview with the CS on 5/5/25 at 11:59 a.m., she indicated she was told…

    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 · E2025-05-12 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to promote a dignified environment with not providing care and services timely and ensure a resident was dressed in street clothes while dining in the facility dining room for 14 of 18 residents reviewed for resident council, 3 of 7 residents reviewed for Activities of Daily Living, 1 of 4 residents reviewed for staffing and 2 of 2 residents randomly observed. (Resident D, Resident E, Resident F, Resident G, Resident H, Resident J, Resident K, Resident L, Resident M, Resident N, Resident O, Resident P, Resident Q, Resident R, Resident S, Resident T, Resident X, Resident V, Resident W, Resident Z, Resident DD, Resident EE and Resident C) Findings include: 1. The clinical record for Resident V was reviewed on 5/12/25 at 11:12 a.m. An admission Minimum Data Set (MDS) assessment, dated 3/21/25, indicated the resident was cognitively intact. On 5/7/25 at 9:53 a.m., Resident V's call light was observed to be on for approximately five minutes. Certified Nurse…

    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 · E2025-05-12 · 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 food was served at a palatable temperature for 14 of 14 residents reviewed for food. (Residents D, F, G, H, J, N, O, Q, R, T, X, 84, Z, and DD) Findings include: 1. The clinical record for Resident DD was reviewed on 5/6/25 at 11:00 a.m. The diagnoses included, but were not limited to, cellulitis. During an interview with Resident DD on 5/6/25 at 11:03 a.m., she indicated the food was delivered cold. 2. The clinical record for Resident 84 was reviewed on 5/5/25 at 11:15 a.m. The diagnoses included, but were not limited to, hypertension. An interview was conducted with Resident 84 on 5/5/25 at 11:37 a.m. She indicated the food was often served cold. 3. The February 2025, March 2025, and April 2025 resident council minutes were provided by the Executive Director (ED) on 5/6/25 at 1:24 p.m. The attendees in the meetings included, but were not limited to: Resident R, Resident Z, Resident X, Resident F, Resident N, Resident H, Resident T, Resident Q, Resident D, Resident J, Resident G, and Resident O. 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 · D2025-05-12 · 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 interview and record review, the facility failed to ensure a resident's medical record was kept private and confidential by giving a resident the wrong medical record in error at discharge for 1 of 3 residents reviewed for discharge. (Resident B and Resident E) Findings include: A. The clinical record for Resident B was reviewed on 5/7/25 at 9:35 a.m. The diagnoses included, but were not limited to, stroke. The resident was discharged from the facility on 10/10/24. B. The clinical record for Resident E was reviewed on 5/12/25 at 12:27 p.m. The diagnoses included, but were not limited to, pain. The resident was discharged from the facility on 10/10/24. During a Confidential Interview, Resident B was given Resident E's medical record at the time of discharge. It was not recognized until 24 hours after discharge from the facility. Resident B had gone to the emergency room with the medical chart that had been given to her by the facility at discharge. At that time, the hospital staff recognized Resident B had been given the wrong resident's medical chart and notified 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 before2025-05-12 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to timely initiate and address a grievance for 1 of 2 residents reviewed for choices (Resident DD). Findings include: The clinical record for Resident DD was reviewed on 5/6/25 at 10:41 a.m. The diagnoses included, but were not limited to, cellulitis (infection) of the right lower limb. She was admitted on [DATE]. A care plan, last reviewed 5/1/25, indicated Resident DD had acute pain related to cellulitis to the right lower extremity and a wound to the right heel. She also had complaints about back pain. She was able to report pain and efficacy of interventions. The goal was for her to have pain levels maintained at a consistent level of comfort while retaining as much function as possible. The interventions were to observe for side effects of treatment interventions, observe for efficacy of interventions, apply non-pharmacological intervention, treatment, and/or removal of the root cause of pain until the issue was resolved, and to monitor vital signs…

    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 · D2025-05-12 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 timely Level I and Level II screening was obtained for 1 of 1 resident reviewed for Pre-admission Screening and Resident Review (PASRR). (Resident 16) Findings include: The clinical record for Resident 16 was reviewed on [DATE] at 2:13 p.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, dementia, bipolar disorder (a mood disorder characterized by episodes of mania and depression), and depression. A facility Social Services admission Screening, dated [DATE], indicated the resident did have diagnoses which may impact adjustment, such as dementia or bipolar disorder. The Executive Director provided a Level I PASRR screen on [DATE] at 1:36 p.m. It indicated the facility completed the screening on [DATE]. The screening also indicated Reason for screening: This nursing facility resident has never had a PASRR Level I screen. The Social Services Director (SSD) was interviewed on [DATE] at 4:28 p.m. She indicated…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-12 · tag F0661 — isolated
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a resident received a discharge summary at the time of discharge for 1 of 3 residents reviewed for discharge. (Resident B) Findings include: A. The clinical record for Resident B was reviewed on 5/7/25 at 9:35 a.m. The diagnoses included, but were not limited to, stroke. The resident was discharged from the facility on 10/10/24. During a Confidential Interview, Resident B was given Resident E's medical record at the time of discharge. She did not receive any of Resident B's medical or discharge information. An interview was conducted with the Executive Director (ED) and the Director of Nursing (DON) on 5/7/25 at 2:22 p.m. The ED indicated Resident B had received Resident E's medical record at the time of discharge by error. Both residents were discharged on the same day, 10/10/24. The medical records were placed in folders sitting on top of the nurse's station. The nurse gave Resident E's medical chart to Resident B by error. A discharge planning policy was provided by the ED on 5/7/25 at 1:36 p.m. It indicated…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-12 · 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 trim a resident's nails and assist a resident with transferring timely for 2 of 7 residents reviewed for activities of daily living (ADL) care. (Resident 200 and Resident 253) Findings include: 1. The clinical record for Resident 200 was reviewed on 5/5/25 at 3:18 p.m. The diagnoses included, but were not limited to, cellulitis (infection) of the left lower limb and depression. She was admitted to the facility on [DATE]. An admission Minimum Data Set assessment, completed 5/7/25, indicated she was cognitively intact. During an interview on 5/5/25 at 3:18 p.m., Resident 200 indicated her nails were long and needed to be trimmed. Resident 200's nails were observed to extend well past the tips of her fingers and have worn green polish on them. On 5/7/25 at 9:54 a.m., the Executive Director provided the shower sheets for Resident 200, which indicated she had a bed bath on 5/6/25. The shower sheet did not indicate if Resident 200's fingernails…

    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
Show the remaining 15 citations
  • Potential for harm · Dcited before2025-05-12 · 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 determine a root cause analysis of falls and to implement fall interventions, as care planned, for 3 of 5 residents reviewed for falls. (Residents' F, 33 and 68) Findings include: 1. The clinical record for Resident 33 was reviewed on 5/5/25 at 1:02 p.m. The diagnoses included but were not limited to Alzheimer's disease. A Quarterly Minimum Data Set (MDS) assessment, completed on 1/29/25, indicated severe cognitive impairment. A progress note, dated 2/24/25 at 3:26 p.m., indicated Resident 33 was seen walking into the television room. She fell after attempting to get onto the weight station. An event report, dated 2/24/25, indicated Resident 33 was fully clothed with her shoes on at the time of the fall, and was incontinent of urine. The clinical record did not contain an Interdisciplinary Team (IDT) note for the 2/24/25 fall. A Significant Change MDS assessment, completed on 2/27/25, indicated she was sometimes able to make herself…

    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 · D2025-05-12 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a resident had a rationale for indication of use and ongoing administration of a prophylactic antibiotic for the prevention of urinary tract infections for 1 of 2 residents reviewed for antibiotic medications and 2 of 5 residents reviewed for unnecessary medications. (Resident 16, Resident L, and Resident 39) Findings include: 1. The clinical record for Resident L was reviewed on 5/5/25 at 11:40 a.m. The diagnoses included, but were not limited to, chronic kidney disease. A care plan, dated 12/16/24, indicated Resident L had a history of urinary tract infections. A nursing note, dated 2/13/25, indicated Resident L's Representative had requested for a prophylactic antibiotic to be given due to the resident's recurrent and history of chronic urinary tract infections. A physician order, dated 2/14/25, indicated the resident was to receive 100 milligrams of Macrobid once a day as a prophylactic for urinary tract infections. A prophylactic antibiotic care plan, dated 2/14/25, indicated the following approaches: staff…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-12 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to serve a diet, as ordered by the physician, for 1 of 1 resident randomly observed for dining (Resident 16). Findings include: The clinical record for Resident 16 was reviewed on 5/5/25 at 12:45 p.m. The diagnoses included, but were not limited to, dysphagia (difficulty swallowing). A physician's order, dated 12/20/24, indicated he was to receive a mechanically altered diet with ground meat. A care plan, last reviewed on 4/8/25, indicated he was noted with dysphagia and had the potential for complications. The goal was for him not to demonstrate dysphagia related complications such as weight loss, signs and symptoms of aspiration pneumonia, or dehydration. The interventions included, but were not limited to, providing diet per physician's order with thin liquids. On 5/5/25 at 12:45 p.m., Resident 16 was observed sitting at a table in the dining room waiting for his meal. A staff member set a plate in front of him with a [NAME] sandwich,…

    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 · Dcited before2025-05-12 · 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 donned a gown prior to administering medication using a nasogastric tube (nasal feeding tube), and prior to urinary catheter and colostomy care for residents on enhanced barrier precautions (EBP) for 1 of 1 resident reviewed for tube feedings and 1 of 1 resident randomly observed during care. (Resident 54 and Resident 210). Findings include: 1. The clinical record for Resident 210 was reviewed on 5/7/25 at 9:30 a.m. The diagnoses included, but were not limited to, dysphagia (difficulty swallowing) and pressure ulcer. On 5/9/25 at 1:57 p.m., Licensed Practical Nurse (LPN) 3 was observed administering medication to Resident 210. LPN 3 prepared the medication at the medication cart and entered the room. She performed hand hygiene and donned disposable gloves, attached the syringe to the nasogastric tube, and administered the medication. LPN 3 then flushed the nasogastric tube with 20 milliliters of water and reconnected the nasogastric tube to the tube feeding. She did not don a gown prior to…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-08 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to ensure accuracy of Minimum Data Set (MDS) assessments regarding restraint use and discharge location for 1 of 1 residents reviewed for Restraint use and 1 of 1 resident received for hospitalization . (Resident 5 and 106) Findings include: 1. The clinical record for Resident 5 was reviewed on 3/8/24 at 11:05 a.m. The diagnoses included, but were not limited to, dementia, impaired mobility, and cerebrovascular accident (CVA). A Quarterly MDS assessment, dated 2/15/24, indicated the chair prevents rising under the restraint section and it was utilized less than daily. There were no care plans for restraint use and/or physician orders for the utilization of a restraint. An Occupational Therapy (OT) note, dated 11/1/23, indicated the utilization of a pommel cushion but no restraint. An interview conducted with the Director of Nursing (DON), on 3/7/24 at 10:00 a.m., indicated the MDS for Resident 5 was miscoded and it was corrected. Resident 5 does not utilize any restraints. 2. The clinical record for Resident 106 was reviewed…

    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 before2024-03-08 · 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

    Based on observation, interview, and record review, the facility failed to ensure a gait belt was utilized during resident transfers and fall prevention measures were implemented during a residents' transfer that led to them being lowered to the ground for 1 of 6 residents reviewed for ADL (Activities of Daily Living) and 1 of 3 residents reviewed for accidents. (Resident 2 and 97) Findings include: 1. The clinical record for Resident 97 was reviewed on 3/7/24 at 11:43 a.m. The diagnoses included, but were not limited to, spinal stenosis, anemia, dysphagia, weakness, lack of coordination, and mixed receptive-expressive language disorder. An admission Minimum Data Set (MDS) assessment, dated 1/16/24, indicated he was cognitively intact, had impairment to one side of the upper extremities, partial/moderate assistance with sit to standing, and partial/moderate assistance with chair/bed-to-chair transfer. An interview conducted with Resident 97, on 3/7/24 at 10:15 a.m., indicated he had fallen a couple of days prior to the interview. The CNA (Certified Nursing Aide) came in and they…

    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 · D2024-03-08 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    2. The clinical record for Resident C was reviewed on 3/7/24 at 3:20 p.m. The diagnoses included, but were not limited to, chronic kidney disease, anxiety disorder, and depression. A physician order, dated 10/2/23, was noted for Wellbutrin SR (sustained release) tablet; 100 milligrams; twice a day from 10/2/23 to 10/6/23. A physician order, dated 10/3/23, was noted for bupropion (generic name for Wellbutrin) tablet; 100 milligrams; twice a day from 10/3/23 to 10/11/23. A pharmacy recommendation, dated 10/6/23, indicated a duplication of therapy and the recommendation to discontinue the order for bupropion tablet 100 milligrams or Wellbutrin tablet 100 milligrams. The electronic medication administration record (EMAR) for October of 2023, indicated the bupropion and Wellbutrin 100 milligrams were administered, as duplicate therapy, on 10/3/23 in the evening, 10/4/23 in the morning and evening, 10/5/23 in the evening, and 10/6/23 in the morning. Based on interview and record review, the facility failed to timely administer an antibiotic, as ordered by the physician, to ensure…

    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 before2024-03-08 · 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 and record review, the facility failed to maintain an infection prevention and control program by not ensuring a urinary catheter's tubing was off of the floor for 1 of 2 residents reviewed for a urinary catheter. (Resident 89) Findings include: The clinical record for Resident 89 was reviewed on 3/7/24 at 9:58 a.m. Resident 89's diagnoses included, but not limited to, urinary tract infection, atrial fibrillation (irregular heartbeat), sacral pressure ulcer stage III, and obstructive and reflux uropathy (difficulties in urination). A Brief Interview for Mental Status (BIMS) assessment completed on 3/6/24 indicated Resident 89 was cognitively intact. An observation of Resident 89 on 3/5/24 at 11:30 a.m. found Resident 89 asleep in his bed and his urinary bag and tubing were lying on the floor. An observation on 3/7/24 at 1:38 p.m. found Resident 89 asleep in his bed with his Foley catheter bag and tubing lying on the floor. Resident 89's care plan dated 1/9/24 indicated, Resident 89 required an indwelling urinary catheter related to obstructive uropathy. One 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-11-22 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to provided an ongoing activity program on the memory care unit of the facility and assist a resident to the activity of her choice in a timely manner for 5 of 6 residents reviewed for activities. (Residents' 28, 61, 77, and 80, 318) Findings include: 1. The clinical record for Resident 80 was reviewed on 11/16/22 at 10:25 a.m. Her diagnoses included, but were not limited to, Alzheimer's disease. Resident 80's 8/22/22 activities care plan, last reviewed/revised on 9/2/22, indicated she would engage in the Cherished Memories model of activities including activities from prior lifestyle, physical, sensory, spiritual, social, and cognitive activities. She enjoyed group games and socials. Interventions were to provide her with an activity calendar to identify activities of interest and for staff to encourage her to engage in preferred group activities like games and socials. The 11/2/22 physician note read, .2. Alzheimer's dementia without behavioral disturbance, unspecified timing of dementia onset .Encourage Brain…

    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 before2022-11-22 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure prompt attention was provided to a resident with concerns regarding missing clothing items and failed to ensure a grievance policy was developed for use with any resident concerns. This deficient practice has the potential to affect all 102 of 102 residents of the health care portion of the facility. (Resident 54) Findings include: In an interview with Resident 54 on 11-21-22 at 10:40 a.m., she indicated she was missing a pair of gray slacks and a pair of lavender Capri pants. She estimated the slacks had been missing for 2 to 4 weeks and the Capri pants had been missing for 2-4 months. She indicated the laundry staff and a nurse were aware of the missing items and had checked the laundry and lost and found items without success. In an interview on 11-21-22 at 11:00 a.m., with the Environmental Service Director, she indicated she was familiar with the 2 missing items belonging to Resident 54. She indicated she had spoken to Resident 54 numerous times and indicated this had been going on for at least four to five…

    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 · D2022-11-22 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    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 criminal background check was obtained for a new hire per facility policy for 1 of 10 personnel files reviewed. (Certified Nursing Assistant (CNA) 15) Findings include: The personnel files of 10 staff members were provided by the Nurse Consultant on 11/21/22 at 8:58 a.m. CNA 15's personnel file was reviewed. It indicated CNA 15's employment start date was 1/26/22. The file included a criminal background check for CNA 15 that had been obtained on 8/25/21. An interview was conducted with the Human Resource Director (HRD) on 11/22/22 at 10:14 a.m. HRD indicated CNA 15 was a new CNA and had completed her clinicals at the facility. The facility had decided to hire her after she had completed her clinical's as a facility employee. HRD had not obtained a criminal background check on CNA 15 prior or at that time of hire. She had used the criminal background check that had been obtained by the school entity for CNA 15. An interview was conducted 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-11-22 · 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, observation, and record review, the facility failed to provide the necessary services to maintain good grooming and personal hygiene for a resident who was unable to carry out activities of daily living by not ensuring twice weekly showers/complete bed baths and providing incontinent care timely for 1 of 4 residents reviewed for activities of daily living (ADLs). Resident 92 Findings include: The clinical record for Resident 92 was reviewed on 11/17/22 at 1:30 p.m. Resident 92's diagnoses included, but not limited to, systemic Lupus, abnormal posture, difficulty in walking, pressure ulcers to bilateral heels (unstageable) and congestive heart failure. Resident 92's admission MDS (minimum data set) dated 11/4/22 indicated, Resident 92 was cognitively intact; required extensive assistance of one person for bed mobility, toileting, and personal hygiene; extensive assistance of two persons for transfers; was frequently incontinent of urine; and indicated it was very important for them to choose between a tub bath, shower, bed bath or sponge bath. An interview 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 · D2022-11-22 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure transportation was provided to a wound care specialist appointment for 1 of 1 residents reviewed for pressure, and to administer eye drops, as ordered by the physician, and to timely inform the physician of a significant weight gain for 1 of 5 residents reviewed for unnecessary medications . (Resident B and Resident 31) Findings include: 1. The clinical record for Resident B was reviewed on 11/18/22 at 2:30 p.m. The diagnosis for Resident B included, but was not limited to, infection of the skin and subcutaneous tissue. A wound specialist visit note dated 9/6/22 indicated Resident B was to be seen for a follow up appointment in 1 week. The consultation indicated .I debrided the wound today. Excisional debridement of the wounds will be performed weekly as long as I feel it is medically necessary until the wound has completely granulated or the wound has healed. My expectation is that I will need to debride weekly for 16+ more weeks . During 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-11-22 · 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

    Based on observation, interview, and record review, the facility failed to implement fall interventions, as care planned, for 2 of 3 residents reviewed for accidents. (Residents 28 and 68) Findings include: 1. The clinical record for Resident 28 was reviewed on 11/16/22 at 10:45 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, diabetes, and hypertension. The 8/2/22 post fall assessment indicated she had an unwitnessed fall in her bathroom on 8/2/22 at 7:00 p.m. with an injury to her head and was transferred to the hospital after the fall. The 8/6/22, 6:41 p.m. nurse's note read, Resident re-admitted to facility at 2:05 p.m. on stretcher accompanied by 2 EMTs [emergency medical technicians.] Resident was at baseline, alert and verbal upon questioned by this nurse. Skin assessment completed, skin tear right upper hand measuring 3 cm X [by] 3 cm with no depth to it r/t [related to] fall and 5 staples to the laceration on posterior scalp on the right side on head, it measures 6 cm. The 10/23/22 post fall event indicated she had an unwitnessed fall in 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
  • No harm found · C2025-05-12 · tag F0577 — widespread
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview, and record review, the facility failed to have the most recent survey results available in the survey binder with the potential to affect 97 of 97 residents currently residing at the facility. Findings include: On 5/7/25 at 10:07 a.m., a resident council meeting was conducted at the facility. During the resident council meeting, a family member indicated they had attempted to read the most recent survey results in the Facility Survey Binder, located by the front entrance. They were unable to view the most recent facility survey. The binder contained survey information from 2022. On 5/7/25 at 10:50 a.m., the Facility Survey Binder was observed with the Executive Director. The most recent survey present in the binder was from December 2022. The Executive Director indicated the Annual Recertification Survey, conducted March 2024, should have been included in the State Survey Binder. He was unsure as to why it was not there. 3.1-3(b)(1)

    Resident Rights 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 CARDON & ASSOCIATES — 19 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 53.7-0.7 vs chain
Health inspection 2 of 53.3-1.3 vs chain
Staffing 4 of 52.5+1.5 vs chain
Quality measures 5 of 54.6+0.4 vs chain
The other 18 homes this chain runs (chain average 3.7★, per CMS)

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
LUMENT REAL ESTATE CAPITAL LLCOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 04/22/2015
ORIX REAL ESTATE CAPITAL LLCOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 04/22/2015
ENGELS, ERINIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 10/12/2012
FENOUGHTY, DEANNAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 07/10/2023
GENTRY, MARKIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 01/12/2022
STARKEY, TYLERIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 08/01/2020
WAITE, JOHNIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 08/01/2020
WHICKER, TIMOTHYIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 01/12/2022
CARDON AND ASSOCIATES INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/23/2013
CARDON MANAGEMENT COMPANY II LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/17/2013
CARDON MANAGEMENT COMPANY LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/17/2013
BALLA, MATTHEWIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/23/2022
CATTELL, ZACHARYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/07/2025
CRAYCRAFT, ALLIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/29/2021
FAUTH, KENDRAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/26/2021
GORMAL, GREGGIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2016
HAUG, AMYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/04/2022
HOYEK, GEORGEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2016
KARNER, JIMIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/18/2012
LOPOSSA, LYNNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/17/2023
MCCLELLAND, THOMASIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/26/2021
MCINTOSH, ERICIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/31/2021
RODGERS, KENTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/04/2021
STEWART, ROBERTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/07/2022
ANKURA CONSULTING GROUP LLCOrganizationADP OF THE SNFsince 06/15/2022
BRADLEY & ASSOCIATES INCOrganizationADP OF THE SNFsince 01/01/2023
COLE MARKETING COMMUNICATIONS INCOrganizationADP OF THE SNFsince 04/01/2015
FORVIS MAZARS LLPOrganizationADP OF THE SNFsince 01/01/2021
HAMILTON TRACE PROPERTY LLCOrganizationADP OF THE SNFsince 04/08/2010
HEALTHDRIVE PODIATRY GROUP PAOrganizationADP OF THE SNFsince 03/07/2019
HEART OF CARDON LLCOrganizationADP OF THE SNFsince 09/06/2007
JEFFREY L MORER OD PCOrganizationADP OF THE SNFsince 03/07/2019
LACY BEYL & COMPANY INCOrganizationADP OF THE SNFsince 07/15/2015
LIFESPAN THERAPY LLCOrganizationADP OF THE SNFsince 10/25/2007
MED-PASS INCORPORATEDOrganizationADP OF THE SNFsince 09/01/2020
MOBILE AUDIOLOGY ASSOCIATES PCOrganizationADP OF THE SNFsince 03/07/2019
MOSER CONSULTING INCORPORATEDOrganizationADP OF THE SNFsince 04/01/2020
RESPIRATORY PARTNERS INCOrganizationADP OF THE SNFsince 11/01/2019
THIRD EYE HEALTH INCOrganizationADP OF THE SNFsince 02/04/2022
VOX GLOBAL LLCOrganizationADP OF THE SNFsince 02/28/2019
SPENCER, LEAANNIndividualADP OF THE SNFsince 06/18/2018
TYLER, LATEASAIndividualADP OF THE SNFsince 05/01/2021

CMS files one row per role, so the 67 rows in the source record cover these 42 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.

21 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.

$20.1M
Net patient revenuemost recent cost report
+1.3%
Operating marginrevenue minus expenses
$6.2M
Related-party expense31% of expenses
Who pays — share of resident-days
Medicaid 21%Medicare 9%Other / private 70%

This home reported $6.2M paid to related parties — landlords or management companies under common ownership — equal to about 31% 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

$311per resident / day
operating cost
$9,455per month
≈ monthly operating cost
$315per 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 155793. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-12, 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.

What to do next