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Golden Years Homestead

3136 Goeglein Rd, Fort Wayne, IN 46815 · Non profit - Corporation · 111 certified beds · (260) 749-9655 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Sep 2024Behavioral-health or dementia-care citation — no harm found (F0740)1 immediate-jeopardy citation$15,646 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • lower-than-typical staff turnover (13% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2024
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $15,646 in federal fines (most recent 2024-01-30)
  • about 19% 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 3 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
Urgent care / clinic
Pharmacy
6310 E State Blvd · (260) 493-1531 · Call to confirm hours
Grocery
2820 Maplecrest Rd · (260) 485-0003 · Call to confirm hours
Park
Jehl Park1.1 mi
1801 Kendawa Dr · 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 4 of 5
Long-stay residentspeople who live here 3 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 improved from 2 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 increased27.6%11.0%15.4%worse
Long-stay residents who lose too much weight6.8%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.2%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection3.8%1.1%2.0%worse
Long-stay residents with depressive symptoms3.9%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 injury5.9%3.9%3.3%worse
Long-stay residents whose ability to walk worsened25.4%11.9%16.1%worse
Long-stay residents on antianxiety or hypnotic medication20.2%23.5%18.9%typical
Long-stay residents given the seasonal flu vaccine97.8%95.4%95.3%typical
Long-stay residents with pressure ulcers2.7%3.6%4.7%better
Long-stay residents with worsening bladder/bowel control25.9%23.3%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table13.8%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 vaccine75.8%79.0%79.4%typical
Short-stay residents rehospitalized after admission19.6%22.2%22.6%better
Short-stay residents with an outpatient ER visit4.9%10.8%12.0%better
Long-stay hospitalizations per 1,000 resident days1.271.611.67better
Long-stay outpatient ER visits per 1,000 resident days0.171.441.80better

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.

48.3% 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 87 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

48.3%U.S. median 51.5%
Got home and stayed home
11.2%U.S. median 10.7%
Went back to hospital
53.5%U.S. median 56.6%
Met the expected recovery
0.26U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 53.5% 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 43 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 0.26 therapist hours per resident per day in 2026Q1 — more than 36% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 21% 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 SNF48.3%CMS range 40.0–57.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.2%CMS range 7.6–15.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge53.5%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 discharge60.5%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 discharge30.2%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 identified92.6%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 discharge96.2%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 stay1.9%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 worsened3.7%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 hospitalization6.7%CMS range 3.8–11.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.851.02Oct 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

0.31
RN hours/ resident / day
0.77
LPN hours/ resident / day
3.02
Aide hours/ resident / day
4.09
Total nurse hours/ resident / day
0.16
RN hoursweekends
12.6%
Total nursing turnover
44.4%
RN turnover

How full it usually is: this home is certified for 111 beds and averages 91.4 residents a day — about 82% occupied, or roughly 20 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.09 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.31 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.02 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.68 hrs/resident/day on weekends vs 4.26 on weekdays — 14% thinner on weekends. RN hours go from 0.37 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 13% is below the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

1
deficiencies at the latest standard inspection (2025-08-05)
3
at the previous standard inspection (2024-09-23)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

21 citations, most serious first. The 11 most serious are shown; the remaining 10 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2024-01-30 · 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 interview and record review, the facility failed to ensure a resident was effectively secured in the wheelchair following manufacturer recommendations during a van transport. This deficient practice resulted in the resident falling out of the wheelchair when a van driver applied the brakes and incurring a spinal injury. (Resident Z) The Immediate Jeopardy began on 1/3/24 when Resident Z slid out of his wheelchair during transport when the facility van made a sudden stop. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on January 29, 2024 at 4:06 P.M. The immediate jeopardy was removed on 1/30/2024 Findings include: On 1/29/24 at 10:25 A.M., Resident Z's record was reviewed. Diagnoses included lumbar stenosis (narrowing of open spaces in lower spine which puts pressure on spinal cord and nerves traveling through the spine). The resident admitted to the facility 12/19/23 for short-term rehabilitation following reconstructive surgery to his spine. On 1/3/24, the resident was seen at the emergency room and diagnosed with a new acute…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-07 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such 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 monitor for adverse side effects of opioid medications with and increased dose for 1 of 3 residents reviewed for pain management. Findings include:A list of recent deaths was provided by the Director of Nursing on [DATE] at 10 AM. The list indicated Resident B passed away on [DATE] at 5:08 AM at the facility.Resident B's record was reviewed on [DATE] at 10:29 AM. Diagnoses included post right hip fracture, Parkinson's, diabetes mellitus, depression and stage 3 chronic kidney disease.Resident B was admitted to the facility on [DATE] for rehab due to a right hip fracture.Active orders included the following for pain:admission order, [DATE] included Hydrocodone- Acetaminophen (Norco) Oral Tablet 5-325 MG - give 1 tablet by mouth every 4 hours as needed for pain.admission order, dated [DATE], indicated give Naproxen Oral Tablet 500 mg - 1 tablet every 12 hours as needed for pain.An order, dated [DATE], indicated to give Oxycodone - Acetaminophen Oral…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-05 · 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 observation, interview, and record review the facility failed to assess mobility for 1 of 4 residents reviewed. (Resident 35) Findings include:During an observation, on 07/30/2025 at 9:59 AM, Resident 35 was in a wheelchair. [NAME] her feet were not resting on foot rest and her chin was tucked with her head tucked sharply to the right and her fists were clenched. During an observation, on 07/31/2025 at 9:50 AM, Resident 35 was sitting in a specialized chair in front of a fireplace with her chin tucked and feet on a footrest. Resident 35's head was all the way to her right and out of the head rest. Resident 35's record was reviewed on 7/31/25 at 11:52am. Her diagnoses included Parkinson's, type 2 diabetes, and unspecified dementia. The record indicated a Minimum Data Set (MDS) assessment (section GG) was completed on 7/11/25 with no impairment to upper extremities.The care plan, dated 7/11/25, was without a specific plan for contractions of upper or lower body. In an interview, on 08/01/2025 at12:56 PM, the MDS coordinator indicated she should have coded hands and shoulder…

    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 before2025-07-17 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure allegations of verbal abuse and mistreatment were reported to the Administrator and state agency within required timeframes for 3 of 5 residents reviewed (Resident B, Resident D, and Resident H).Findings include:A report, dated 6/29/25, alleged Resident B and Resident H were involved when Certified Nurse Aid (CNA) 5 had yelled at the residents and not provided care according to their individual care plans. The report alleged the incidents had been reported to management, but nothing had been done. The report indicated Resident D had alleged physical abuse, reported to Human Resource staff instead of the Administrator or Director of Nursing (DON) per facility policy, and no investigation had allegedly been done.1.The report, dated 6/29/25, alleged on 5/26/25, Resident B had wanted to have his brief changed and had been trying to get staff's attention. He had been seated in his wheelchair next to his bed. His call light was on the other side of the bed and out of his reach. Employee 2 indicated they had observed 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-07 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a resident was administered medication as ordered by the physician for 1 of 3 residents reviewed (Resident Q). Findings include: On 5/7/25 at 10:45 A.M., Resident Q's record was reviewed. Diagnoses included epilepsy with partial seizures and dementia. A physician order, dated 11/14/25, indicated to give Levetiracetam (anti-seizure medication) 750 milligrams (mg); take 1 tablet by mouth every 12 hours for seizures. A physician order, dated 4/30/25, was to discontinue Levetiracetam 750 mg; take 1 tablet by mouth every 12 hours and start Lacosamide 100 mg tablets; take 1 tablet by mouth 2 times per day for seizures. An Interdisciplinary (ID) note, dated 4/30/25 at 2:05 p.m., indicated Resident Q had gone out for an appointment with the Neurologist. She returned to the facility with new orders to discontinue Levetiracetam and begin Lacosamide 100 mg tablets; take 1 tablet by mouth 2 times per day for seizures. The pharmacy was notified of the change in orders. A Medication Administration Record (MAR), dated May 2025,…

    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 · D2025-05-07 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    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 inappropriate touching behavior was identified, prevention interventions implemented and the behavior trended for 2 of 3 residents reviewed for behaviors (Resident D and Resident E). Findings include: Reports, dated 4/12/25 and 4/13/25, alleged Resident D had inappropriately touched a female resident (Resident E) on her legs and chest. Both reports indicated there had been no documented interventions put in place to protect the residents and ensure no further inappropriate touching occurred. The reports alleged there was no documentation in either resident's record regarding the behaviors on 4/7/25. 1. On 5/5/25 at 1:44 P.M., Resident D's record was reviewed. Diagnoses included, Parkinson's, dementia, anxiety, and depression. A quarterly Minimum Data Set (MDS) assessment, dated 2/6/25, indicated a Brief Interview Mental Status (BIMS) assessment indicated Resident D had no cognitive impairment. He had several mood indicators as follows: little interest or pleasure in doing things, feeling down,…

    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 · D2025-05-07 · 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

    Based on interview and record review, the facility failed to maintain complete and accurate medical records for 2 of 3 residents reviewed (Resident D and Resident E). Findings include: Reports, dated 4/12/25 and 4/13/25, alleged Resident D had inappropriately touched a female resident (Resident E) on her legs and chest. Both reports indicated there had been no documented interventions put in place, following the alleged incident, to protect the residents and ensure no further inappropriate touching occurred. The reports alleged there was no documentation in either resident's record regarding the incidents on 4/7/25. 1. On 5/5/25 at 1:44 P.M., Resident D's record was reviewed. Diagnoses included, Parkinson's, dementia, anxiety, and depression. An Interdisciplinary (ID) note, dated 4/7/25 at 11:47 p.m., indicated the nurse had been notified by staff, Resident D had engaged in inappropriate behavior throughout the day. The nurse notified the Director of Nursing (DON) and Assistant Director of Nursing (ADON). An ID note, dated 4/8/25 at 3:26 p.m., indicated the hospice case manager had…

    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 · E2024-09-23 · 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, interview and record review, the facility failed to ensure medications were dated when opened, and destroyed when expired in 2 of 4 medication carts. Findings include: During an observation, on [DATE] at 1:36 PM, with License Practical Nurse (LPN) 4 on the D hall medication cart, Trelegy 100/ 62.5, inhaler was without a box and no open date for Resident 47. LPN 4 indicated medication should not be in the cart without the date. During an observation on [DATE] at 1:50 PM, with Qualified Medication Aide (QMA) 5 on C hall medication cart, there was an open bottle of Nystatin [NAME] 100 mg with no open date for Resident 27. On the second medication Cart on C hall with QMA 5, was a bottle of Lidoncaine Sol 2% oral with no open date for Resident 25. In the same medication cart, was the medication Insulin Lispro INJ 100 U with an open date of [DATE] and an expiration date of [DATE] for Resident 37. In the same drawer there was a medication of Lantus INJ 100 U with an open date of [DATE] 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-23 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    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 1 of 5 residents reviewed were free of abuse. (Resident 26). Findings include. Resident 26's record was reviewed 9/17/24 at 2:18PM. Resident 26's diagnoses included dementia, depression, and muscle weakness. A Minimal Data Set (MDS) assessment, dated 8/21/24, indicated Resident 26's Brief Interview for Mental Status score (BIMS ) was 3. A score of 3 indicated severe cognitive decline. Section E of MDS indicated Resident 26 had no behavioral symptoms of aggression. Resident 26 was continent of bowel and used a catheter due to urine retention. Resident 26's care plan, dated 9/17/24, indicated he had cognitive loss. Interventions were to allow plenty of time for care, do not rush or push, do not show impatience. Resident 26's care plan, dated 9/17/24, had a problem of argumentative behavior and becoming agitated easily by others. Interventions were to please intervene as needed to ensure safety and the safety of others, please talk with resident in calm manner; do not give directions, do not argue.…

    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 before2024-09-23 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    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 interventions were implemented to prevent feelings of fear for 1 of 2 residents reviewed. (Resident 3) Findings include: In an interview, on 9/17/24 at 11:09AM, She indicated she had been overwhelmed since her husband's passing in May 2024. Resident 3 pointed to several boxes against the wall across from her bed of memorabilia she felt responsible to sort and disperse to family members. Resident 3 explained her diagnosis of PTSD realted to sexual, verbal, and physical abuse as a child. Resident 3 indicated the only times she was triggered in the facility was when a peer (Resident 85) was coming into her room uninvited especially at night. Resident 3 described a male peer coming into her room sometimes making it to the foot of her bed before she would see him or feel him looking at her. Resident 3 reported she would be the one to alert staff to his continued unwanted presence in her room, and he would be redirected back to his 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-23 · 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 infection control measures were maintained for oxygen tank tubing for 2 of 3 residents reviewed. (Resident 16 and Resident 247) During an observation, on 9/17/24 at 12:20 PM, there were 2 oxygen tanks in the hallway on the floor. The tubing for both tanks were observed to be wrapped around the hand rail outside of the beauty shop. There were no covers, any bags, or dates observable for the tubing to be placed into. In an interview, on 9/17/24 at 12:25 PM, the Director of Nursing (DON), indicated the resident would wear their oxygen to the beauty shop and leave the tank outside. 1. A record review of Resident 16 was completed on 9/17/24 at 1:05 PM. Diagnosis included, chronic obstructive pulmonary disease. A physician order for Oxygen 2 liter (L)/ min, indicated to give nasal oxygen every shift for chronic obstructive pulmonary disease with (acute) exacerbation. 2. A record review of Resident 247 was completed on 9/17/24 at 1:05 PM . Diagnosis included, dependence on supplemental oxygen. A physician order…

    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
Show the remaining 10 citations
  • Potential for harm · Dcited before2024-04-04 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to enure an injury of unknown origin was reported for 1 of 3 residents reviewed (Resident D). Findings include: On 4/4/24 at 1:27 P.M., Resident D's record was reviewed. Diagnoses included dementia with behavioral disturbance. An IDT (Interdisciplinary Team) note, dated 2/26/24 at 11:00 a.m., indicated the resident was observed with swelling and discoloration of the right side of her face. She was not wearing her dentures becasue they were broken. The resident's family was notified of the swelling and broken dentures. The family member indicated too the IDT they were aware of the injury to her face and had taken her to the ER on [DATE] to be evaluated and treated. A late entry progress note dated 2/23/24 at 4:00 p.m., indicated the resident's right cheek and side of her face had been swollen without bruising. An IDT note, dated 3/23/24 at 12:27 p.m., indicated Resident D had swelling near and blue bruising below her right eye. She had no signs 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-12 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the physician and family timely of a significant change in condition for 1 of 1 residents reviewed (Resident D). Findings include: On 3/11/24 at 10:57 A.M., Resident D's family member/POA (Power of Attorney) was interviewed. The family member indicated the resident had been admitted to the facility following hospitalization for C. Diff colitis (Clostridium Difficile infection of colon). She had completed her therapy and family was waiting until her C. Diff infection was completely resolved to take her home due to home health refusing to provide care at home with an active C. Diff infection. The POA alleged on 12/25/23, another family member had been in to visit the resident. Reidnet D complained of right sided pain in her midsection. The family indicated they did not inform the facility. On 12/27/23, 2 other family members visited and the resident was observed to grab at her right side and stated oh that hurts. Family asked staff to assess 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 · E2024-01-30 · tag F0865 — failed to run a quality-improvement (QAPI) program — pattern
    Have a plan that describes the process for conducting QAPI and QAA activities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to implement a comprehensive QAPI program to ensure residents were provided with safe transportation provided by the facility. 43 of 90 residents residing in the facility utilized van transportation. Findings include: During a complaint survey, dated 1/29/24 to 1/30/24, a deficiency was cited at Immediate Jeopardy-F689 when the facility failed to ensure a resident was secured in the wheelchair following manufacturer recommendations during transport. The resident slid out of the wheelchair and onto the floor when the transportation van made an abrupt stop causing the resident to sustain a spinal injury. Cross reference F689. On 1/29/24 at 9:52 A.M., the Administrator was interviewed. He indicated the facility conducted an investigation of the incident occurring on 1/3/24 which resulted in a resident's injury. During interviews, he determined staff had secured the resident with the harness belt as trained per manufacturer's recommendations. According to staff, use of a lap belt along with the harness belt was…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-12 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    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 preferences and options for showers and meals were offered and observed for 1 of 2 residents reviewed. (Resident 40) Findings include: During an interview on 9/8/23 at 11:26 AM, Resident 40 indicated the inability to have meal options or to choose shower times and days was concerning. Resident 40 indicated they only got whatever meal that was available to them. They did not get to choose other options. Resident 40 further indicated she did not get her showers on Wednesday and Saturdays as she was told she would. When she gripes loud and hard enough she may get a shower on Thursdays when it was conveient for the staff. She preferred shower times to be in the afternoon. Resident 40's record review began on 9/8/23 at 2:19 PM. Diagnoses included, chronic obstructive pulmonary disease with acute exacerbation. Resident 40's BIMS (brief interview mental status) was a 13 out of 15 (cognitively intact). A physician order dated 5/18/23, indicated a diet order of regular with mechanical soft textures. During an interview on…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-12 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to ensure physician orders were followed for 2 of 2 residents reviewed. (Resident 9 and Resident 198) Findings include: 1 In an interview on 9/6/23 at 1:04 PM, Resident 9 and her daughter indicated she was confused. Resident 9 indicated the bandage on her leg was from a fall she had at a named facility. Resident 9 was unable to idientify her current facility. Resident 9 was unable to recall why she fell or when. Resident 9 complained of being tired but denied any other complaints. Resident 9's daughter indicated there were times her mother's pain medication was not available when it was to be given. The daughter had no other complaints. In an interview, on 9/11/23 at 1:31PM, RN 4 indicated she removed (2) 25mcg Fentanyl patches and a 100mcg Fentanyl patch from Resident 9 and replaced them with a 100mcg Fentanyl patch. RN 4 indicated there was a onetime order for the (2) 25mcg patches until the 100mcg patches were received from the facility pharmacy. Residents 9's record review began on 9/11/23 at 2:22PM, her diagnoses included…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-12 · 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 ensure safety for 1 of 5 people reviewed. (Resident 9) During an observation and interview with Resident 9 on 9/6/23 at 1:04 PM she appeared with a white criss cross bandage wrapped around leg. She indicated she fell at a facility and referred to it as some place else. She was unable to indicate when or how she fell. She was unable to tell what she had for breakfast or lunch. During an interview on 9/11/23 at 1:08PM, Resident 9 did not remember going outside at all. Resident 9 indicated she blacks out at times. She was further able to indicate the memory loss was off and on. Resident 9 complained of being tired. During an interview on 9/11/23 at 1:11PM, Resident 9's daughter indicated Resident 9 had began to wander and more confused in the last two months. The daughter was unable to indicate where the Resident 9 was found or how long she was missing. The daughter indicated she got a phone call to explain Resident 9 eloped and refused 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-12 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to provide adequate pain management for 1 of 3 residents reviewed. (Resident 13). Findings include: During an observation and interview on 9/6/23 at 9:52AM, Resident 13 was lying in bed clutching one hand inside of the other. Resident 13 indicated he was always in pain. Resident was aware of his diagnoses and medications. Resident 13 indicated he did not receive any non-pharmaceutical interventions for his pain prior to as needed narcotic pain medication. Resident 13 indicated he tried not to take the medication on days he did not have therapy. Resident13 rated his pain during this interview a 7 with the majority being in his hands and back. Resident 13 indicated when he was home and able to care for himself running his hands under warm water helped loosen up the joints and greatly improved the pain and mobility. During an observation and interview with Resident 13, on 9/7/23 at 11:18 AM, in his room sitting in a wheelchair next to his bed. During this interview he rated his pain an 8. He described the pain as…

    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 before2023-09-12 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to ensure residents receive culturally competent, trauma-informed care for 1 of 1 residents reviewed (Resident 49). Findings include: Resident 49's record was reviewed on 09/06/23 at 11:44 AM. Diagnoses included cognitive communication deficit, major depressive disorder, and history of falling. There was no PTSD (Post Traumatic Stress Disorder) diagnosis present at time of review. A review of Resident 49's current quarterly MDS indicated their BIMS (Basic Interview for Mental Status) score was 15 (cognitively intact). There were no care plans for PTSD. A review of progress notes dated 08/01/2023 at 2:40 PM indicated Resident 49 informed the Nurse Practitioner (NP) of recent PTSD flare ups caused by loud noises, scaring Resident 49. In an interview on 09/08/23 at 11:53 AM, Resident 49 indicated they had not been depressed recently, but loud noises have been more irritating, upsetting and recalling PTSD situations. Resident 49 indicated they had spoken to the NP regarding these concerns. A current policy dated 03/01/2023…

    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 · D2023-09-12 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview, observation, and record review the facility failed to ensure to maintain a sanitary kitchen for 3 of 3 observations. Findings include: 1. In an interview on 9/6/23 at 9:47 AM, the Dietary Manager (DM) indicated the kitchen had a low temperature dishwasher. During an observation on 9/6/23 at 9:47 AM, the dishwasher wash was 80 F and the rinse was 85 F. During an observation on 9/6/23 at 1:06 PM, the dishwasher wash was 82 F and the rinse was 82 F. In an interview on 9/6/23 at 1:06 PM, the DM indicated this was a normal temperature for the dishwasher. An email, dated 9/6/23, by the dishwasher servicing company was provided by the DM at 1:06 PM. The email indicated the wash temperature should be 120 F and the rinse should be 50-100 parts per million for chlorine to properly sanitize. A policy was requested from the Director of Nursing (DON) on 9/6/23 at 1:28 PM. The facility did not provide a policy by the survey exit. 3.1-21(i)(3)

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-12 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview the facility failed to ensure garbage and refuse were contained inside the dumpster for 2 of 3 observations. Findings include: During an observation on 9/6/23 at 9:56 AM with the Dietary Manager, there were 2 bags of trash, piles of used gloves, and 2 empty cardboard containers on the ground around the dumpster. In an interview on 9/6/23 at 9:56 AM, the Dietary Manager indicated the maintenance department maintained the dumpster. The Dietary Manager indicated there should not be trash lying around the dumpster. The Dietary Manager also indicated the trash present appeared as it had been on the ground for awhile. In an interview on 9/6/23 at 10:04 AM, the Maintenance Director indicated the maintenance department maintained the cleanliness of the dumpster. The Maintenance Director indicated there should not be trash lying around the dumpster. The Maintenance Director also indicated the trash appeared as it had been on the ground for a long time. In an interview on 9/6/23 at 1:28 PM, the Director of Nursing (DON) indicated the dumpster should not have…

    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

“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

$15,646 in federal fines across 1 penalty.

  • $15,646 — penalty dated 2024-01-30

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

Part of a chain

This home belongs to GREENCROFT COMMUNITIES — 5 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 52.6+0.4 vs chain
Health inspection 3 of 52.0+1.0 vs chain
Staffing 3 of 53.6-0.6 vs chain
Quality measures 4 of 54.6-0.6 vs chain
The other 4 homes this chain runs (chain average 2.6★, 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 / managerTypeRoleShareSince
WOODLAWN HOSPITALOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 07/01/2018
BULLION, GEORGEIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/1995
CARPENTER, MICHAELIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2000
DAVIS, HUGHIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/05/2024
DEAN, DALEIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/1997
ELICK, CYNTHIAIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2015
HEYDE, ALISONIndividualCORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 09/09/2019
JOHNSON, TERRIIndividualCORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 06/13/2022
MCINTOSH, RAYIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2011
MELLINGER, GREGORYIndividualCORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 06/13/2022
MISNER, DONNAIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2020
OLINSKI, LYNDAIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/08/2020
SCHMIDT, DONIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2006
SHAW, DOUGIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
SMITH, LINDAIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2022
VANWYNGARDEN, ANDREAIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2018
VILLARREAL, JEANNINEIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2022
FISHER, ALANIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNFsince 06/13/2022
GOLDEN YEARS HOMESTEAD, INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 07/01/2018
BALTES, CHRISTOPHERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/07/2019
SHAFER, SHAUNAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/12/2025
BODE, GLENIndividualTRUSTEE OF THE SNFsince 12/09/2022
CHUDZYNSKI, KENDRAIndividualTRUSTEE OF THE SNFsince 10/15/2024
MILLER, BRANDONIndividualTRUSTEE OF THE SNFsince 04/07/2025
WEBB, HARRYIndividualTRUSTEE OF THE SNFsince 10/15/2023

CMS files one row per role, so the 58 rows in the source record cover these 25 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$14.2M
Net patient revenuemost recent cost report
-5.7%
Operating marginrevenue minus expenses
$2.8M
Related-party expense19% of expenses
Who pays — share of resident-days
Medicaid 54%Medicare 4%Other / private 41%

This home reported $2.8M paid to related parties — landlords or management companies under common ownership — equal to about 19% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$420per resident / day
operating cost
$12,783per month
≈ monthly operating cost
$398per 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 155755. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-05, 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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