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Kingston Health Center of Fort Wayne

1010 W Washington Center Rd, Fort Wayne, IN 46825 · For profit - Corporation · 137 certified beds · (260) 489-2552 Medicare & Medicaid certified

Call the home — (260) 489-2552 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 25 lower-level deficiencies on record (see below)
Insights

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

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • nursing-staff turnover (61%) runs well above the national median (45%)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
5932 Stoney Creek Dr. · (260) 483-3966 · Call to confirm hours
Pharmacy
6736 Lima Rd · (260) 490-0638 · Call to confirm hours
Grocery
5831 Cross Creek Blvd · (260) 490-8518 · Call to confirm hours
Park
6601 Innovation Blvd · Typically dawn to dusk
Place of worship
1400 W Washington Center Rd · (260) 490-8585

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased4.9%11.0%15.4%better
Long-stay residents who lose too much weight6.0%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.3%1.1%2.0%better
Long-stay residents with depressive symptoms8.3%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 injury2.0%3.9%3.3%better
Long-stay residents whose ability to walk worsened1.6%11.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication11.2%23.5%18.9%better
Long-stay residents given the seasonal flu vaccine97.8%95.4%95.3%typical
Long-stay residents with pressure ulcers3.0%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 table11.3%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 vaccine84.2%79.0%79.4%typical
Short-stay residents rehospitalized after admission12.5%22.2%22.6%better
Short-stay residents with an outpatient ER visit10.9%10.8%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.521.611.67typical
Long-stay outpatient ER visits per 1,000 resident days0.941.441.80better

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.

61.7% 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 204 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

61.7%U.S. median 51.5%
Got home and stayed home
9.9%U.S. median 10.7%
Went back to hospital
66.7%U.S. median 56.6%
Met the expected recovery
0.60U.S. median 0.31
Therapy hours / resident / day
0.34hours / resident / day
Physical therapy
0.21hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 66.7% 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 78 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 0.60 therapist hours per resident per day in 2026Q1 — more than 88% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% 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 SNF61.7%CMS range 55.5–67.251.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.9%CMS range 7.3–13.110.7%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 discharge66.7%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 discharge60.3%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 discharge53.9%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 identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting93.9%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 discharge93.2%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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.9%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 hospitalization7.2%CMS range 4.5–12.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.841.02Oct 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

0.93
RN hours/ resident / day
0.82
LPN hours/ resident / day
2.34
Aide hours/ resident / day
4.09
Total nurse hours/ resident / day
0.79
RN hoursweekends
60.7%
Total nursing turnover
54.2%
RN turnover

How full it usually is: this home is certified for 137 beds and averages 102.2 residents a day — about 75% occupied, or roughly 35 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 0.93 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.34 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 3.65 hrs/resident/day on weekends vs 4.27 on weekdays — 14% thinner on weekends. RN hours go from 0.99 to 0.79 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 61% is well above 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

6
deficiencies at the latest standard inspection (2025-06-25)
6
at the previous standard inspection (2024-08-26)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

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 · Ecited before2025-11-20 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, observation and record review the facility failed to follow sanitation methods to maintain a clean environment in the kitchen area. 107 of 107 residents who resided in the facility ate food prepared in the kitchen.Findings include:During an observation, on 11/19/25 at 10:20 AM, 22 plus live gnats were observed in the dining room corner, on the opposite wall from the dishwasher. There were 3 carts covered in dried yellow and white liquid. There were also 3 carts of leftover food from breakfast waiting to be washed.During an interview, on 11/19/25 at 10:21 AM, the Dietary Manager (DM) indicated pest control had treated the gnats and it had resolved. The DM indicated there had been increased cleaning of the area and the carts were cleaned nightly. The DM indicated there was no documentation for nightly cart cleaning. The DM indicated the carts observed in the dining room had not been cleaned nightly based on appearance.During an interview, on 11/19/25 at 10:37 AM, the Maintenance Director indicated the pest control company had treated the area for gnats last week.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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-11-20 · tag F0925 — failed to control pests — pattern
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    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 follow sanitation methods to prevent pests. 107 of 107 residents who resided in the facility ate food prepared in the facility kitchen.Findings include:During an observation on 11/19/25 at 10:20 AM, 22 plus live gnats were observed in the dining room corner, on the opposite wall of the dishwasher. There were 3 carts covered in dried yellow and white liquid. There were also 3 carts of leftover food from breakfast waiting to be washed.During an interview on 11/19/25 at 10:21 AM, the Dietary Manager (DM) indicated pest control had treated the gnats and it had resolved. The DM indicated there had been increased cleaning of the area and the carts were cleaned nightly. The DM indicated there was no documentation for nightly cart cleaning. The DM indicated the carts observed in the dining room had not been cleaned nightly based on appearance.During an interview, on 11/19/25 at 10:37 AM, the Maintenance Director indicated the pest control company had treated the area for gnats last week.A pest control log was provided…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-20 · 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 follow physician orders for 1 of 4 records reviewed. (Resident B).Findings include:In an interview on 11/19/25 at 12 PM, Resident B's family indicated Resident B re-admitted to the facility on [DATE] evening from the hospital. Resident B's family indicated Resident B missed her antiseizure medication on 11/19/25 at 8 PM and 11/20/25 at 8 AM. Resident B's family indicated they were notified on 11/20/25 Resident B had a seizure on 11/20/25 at 6 PM. Resident B's family indicated they were not notified of the missed medication dosage or unavailability of medication. Resident B's family indicated when Resident B missed a dose of her antiseizure medication, Resident B had a seizure.Resident B's record was reviewed on 11/19/25 at 12:16 PM. Diagnosis included epilepsy, hemiplegia and diffuse traumatic brain injury. A Hospital Medication Administration Record (MAR), dated 10/13/25 - 10/19/25, indicated Resident B received lacosamide/vimpat (antiseizure…

    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 · E2025-06-25 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure a license was current for 1 of 159 licensed staff. (Qualified Medical Assistant (QMA) 9). Findings include: A review of the facility licensure book, on [DATE] at 12:PM, indicated QMA 9's license expired on [DATE]. In an interview, on [DATE] at 1:45PM, the Administrator was informed QMA 9's license was expired. In an interview, on [DATE] at 10:30AM, the administrator provided QMA 9's license renewed [DATE]. The Administrator was unsure if QMA 9 had worked any hours while the license was expired. In an interview, on [DATE] at 11:15 AM, the DON indicated the dates QMA 9 worked in the facility without a license was [DATE] and [DATE]. A timesheet was provided by the DON, on [DATE] at 12:18PM, for QMA 9 indicated she had worked on [DATE] and [DATE] administering medications on a hall to 10 residents. No policy was provided by time of exit. 3.1-17(b)(1)

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-25 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure safe sanitization parameters were maintained for cleaning solutions used in the kitchen. 106 of 109 residents eat food prepared in the facility kitchen. Findings include: During an observation, on 06/19/25 at 09:15 AM, the following was observed: the Dietary Manager (DM) performed dipstick testing on the red sanitization bucket in the main kitchen. The solution did not cause the test strip to change color. The DM indicated the test strip should change color to confirm the solution is a minimum of 150ppm (parts per million). The DM indicated chemical release towels were used that [NAME] chemical solution into the water in the bucket The bucket was emptied, refilled, and new chemical release towels were placed in the water. During an observation, on 06/19/25 at 10:30 AM, the Dietary Manager performed dipstick testing in the main kitchen and the test strip did not change colors. The DM indicated the water still did not meet the minimum requirements…

    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 · D2025-06-25 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure a bed hold policy was given prior to discharge to 3 of 3 residents reviewed. (Resident 26, Resident 28, and Resident 109) Findings include: 1) Resident 26's record review began on 06/20/25 at 01:11 PM. Diagnoses included stroke, heart failure, and seizures. A reveiw of progress notes, dated 10/14/24, indicated Resident 26 was sent to the hospital. There was no mention of a bed hold being explained to her or family in the progress or event notes. The facility provided an unsigned and undated discharge packet, The notice of transfer and discharge had a section requiring a signature and date which was left blank. The [NAME] Bed Holds and Leaves of Absence form had a place to designate whether the resident or resident representative prefers a bed to be held or do not hold a bed. The Bed Hold form further required a signature and date. On the form given, dated 10/14/24, all of the information was left blank. Progress notes indicated, on 11/21/24,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-25 · 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 observation, interview and record review the facility failed to ensure facial hair and nail care was provided for 1 of 10 residents reviewed (Resident 41). Findings include: During an observation, on 6/20/25 at 1:36 PM, Resident 41 was observed in the dining room with many white chin hairs about 2 cm long and dark brown debris present under her first, second, and third fingernails of her right hand. During an observation, on 6/23/25 at 9:12 AM, Resident 41 was observed in the dementia care dining room eating her breakfast with dark brown debris under the nails of her right 2nd 3rd and 4th fingernails and 4th and 5th fingernails of her left hand. Her breakfast meal was scrambled eggs and toast, with no food item matching the color of the debris under her nails. Resident 41 had many white hairs about 3 cm long on her chin and upper lip. During an interview, on 6/23/25 at 9:23 AM, Certified Nurse Aide (CNA) 4 indicated Resident 41 had dark brown debris under her fingernails on both hands. She indicated it was dark brown and did not match the color of any item she ate that…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-25 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure physician's orders were followed for 1 of 1 residents reviewed. (Resident 112) Findings include: During an observation, on 06/19/25 at 09:25 AM, the oxygen concentraor in Resident 112's room was turned off, and the nasal cannula was secured in a plastic bag on top of the machine. Resident 112 was in the bed with his eyes closed. During an observation, on 06/20/25 at 09:40 AM, the oxygen machine in Resident 112's room was turned off, and the nasal cannula was secured in a plastic bag on top of the machine. Resident 112 was resting in bed. His respirations were easy. During an observation, on 06/23/25 at 09:29 AM, oxygen was placed on Resident 112 via nasal cannula at 5LPM (liters per minute). Employee 5 indicated in an interview, on 6/23/25 at 9:30 AM, Resident 112 had a change in condition and oxygen was placed on him via nasal cannual at 5LPM. During an observation, on 06/23/25 at 01:41 PM, Resident 112's oxygen was running via nasal cannula at a rate of 5LPM. During an observation, on 06/24/25 at…

    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 · D2025-06-25 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for 2 of 3 residents reviewed. (Resident 17 and Resident 163) Findings include: 1) Resident 17's record review began on 06/23/25 at 02:17 PM. Resident 17's diagnoses included end stage renal disease, diabetes, and hypertension. Resident 17 had a physician order for dialysis on Tuesdays, Thursdays, and Saturdays. A review of Resident 17's dialysis communication book indicated the Hemodialysis communication forms had the following missing information: - 6/14/25 Had no communication from the dialysis center. No vital signs. No weight. No run time. No dry weight. No post dialysis assessment. No information regarding if there were any complications. No information regarding medications given. No information regarding if labs were drawn. - 6/17/25 Had no communication from the dialysis center. No vital signs. No weight. No run time. No dry weight. No post dialysis assessment. No information regarding if there were any…

    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 · D2025-06-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure an exit door remained secure for 1 of 5 residents reviewed (Resident 98). Findings include: Resident 98's record was reviewed on [DATE] at 10:19 AM. Diagnoses included Alzheimer's disease with early onset, restlessness and agitation, and psychotic disorder with delusions due to known physiological condition. A review of Resident 98's current admission Minimum Data Set Assessment (MDS), dated [DATE], indicated their Basic Interview for Mental Status (BIMS) score was 10 (cognitively impaired). The MDS indicated Resident 98 had displayed verbal behavioral symptoms toward others 1-3 days per week and puts others at risk of significant risk of physical injury. The MDS indicated Resident 98 wandered with a significant risk of getting into potentially dangerous places. A review of Resident 98's current care plan titled Risk for Elopement indicated the resident had a problem of being independently ambulatory, having dementia, exit seeking…

    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 · D2025-05-15 · 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 observation, interview and record review, the facility failed to ensure grievances were thoroughly investigated, contained required documentation, and appropriate corrective actions taken for 1 of 3 residents reviewed with grievances (Resident Q). Findings include: A report, dated 4/23/25, alleged Resident Q was rushed and handled roughly during personal care provided by Certified Nurse Aide (CNA) 2. On 5/14/25 at 12:55 P.M., Resident Q's record was reviewed. Diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) following a stroke affecting the right side. A nurse note, dated 4/6/25 at 1:26 p.m., indicated Resident Q had arrived to the facility from the hospital. She was alert, oriented and able to make her needs known to staff. She'd had a recent stroke with expressive aphasia (difficulty speaking fluently) and paralysis on the right side. She reported having some pain on her entire right side. She required assistance of 1 with completing her activities of daily living (ADL). A respiratory therapy note, dated 4/10/25 at 9:55 a.m., indicated Resident Q was 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-14 · 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 surgical wound was assessed and monitored for 1 of 3 residents reviewed (Resident P). Findings include: On 3/14/25 at 11:15 A.M., Resident P's record was reviewed. Diagnoses included dementia with behavioral disturbance and fracture of the right femur (12/23/24). A nurse note, dated 12/17/24 at 6:35 p.m., indicated Resident P had a fall and was observed on the floor of room in his doorway. The resident was yelling in pain and holding his right hip. He was sent to the emergency room for evaluation and treatment. A hospital operative report, dated 12/19/25, indicated the resident had fallen and fractured the top of his right femur. A right hip cemented hemiarthroplasty (replacing the ball at the top of the femur bone with a metal implant and securing with cement-National Institue of Health) was performed and the surgical incision closed with staples. An admission Evaluation, dated 12/23/24 at 4:00 p.m., indicated Resident P was readmitted to the facility from the hospital. He was alert and denied pain. He was bed…

    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 · D2024-10-21 · 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 ensure complete and accurate medical records were maintained for 1 of 3 residents reviewed (Resident D). Findings include: On 10/18/24 at 2:21 P.M., Resident D's spouse was interviewed. During the interview, she indicated several concerns with the care provided the resident during his stay. She alleged Resident D's medication to treat his bi-polar disorder was decreased and a new medication given. She had spoken with the Nurse Practitioner (NP) and indicated she had not wanted the residents medication to be decreased and had not wanted him to be placed on a new medication. Additionally, she alleged the staff hadn't noticed the resident had no teeth or dentures and had not served him soft foods. She indicated the resident was given food he was unable to chew so he just hadn't eaten. On 10/18/24 at 3:07 P.M., Resident D's record was reviewed. Diagnoses included bradycardia (slow heart rate), chronic obstructive pulmonary disease (COPD), chronic kidney disease, diabetes, dementia and bi-polar disorder. 1. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-26 · 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 observation, interview, and record review the facility failed to ensure a dignified dining experience for 5 of 20 residents reviewed (Resident 49, Resident 76, Resident 77, Resident 82, and Resident 100). Findings include: During an observation on 8/21/24 at 12:46 PM, Resident 49, Resident 76 and Resident 82 were seated together at a table. Resident 49 and two unidentified residents had plates of food in front of them, but Resident 76 and Resident 82 had not yet been served. [NAME] 8 served trays to each table where other residents were waiting before taking lunch orders for Residents 76 and 82. Resident 76 and Resident 82 were served lunch at 1:18 pm. Resident 49 did not engage in eating tasks until her tablemates were served. Resident 49 indicated her food had become cold while she waited to eat. During an observation and interview on 8/21/24 at 1:19 PM, Resident 77 picked up plates, glasses and silverware from tables, placing them in a large dishpan on top of a cart. Resident 77 propelled herself by…

    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 · E2024-08-26 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure pureed food was prepared to guideline specifications. 5 of 5 residents requiring pureed diets consumed food prepared by the dietary staff. (Resident 5, Resident 10, Resident 27, Resident 39, and Resident 68). In an observation followed by an interview, on 8/20/24 at 11:16AM, [NAME] 8 identified a pan of meat with charred spots, and sticking to wax paper as pork tenderloin. [NAME] 8 took 8 varied size pieces of the meat and put into the grinder adding 3 soup ladles of gravy. [NAME] 8 was shaking the grinder and then using a spatula to wipe the sides. [NAME] 8 added 1 additional ladle of gravy. There was no recipe visible. [NAME] 8 indicated she was unable to determine the measurement of soup ladle. [NAME] 8 asked [NAME] 7 if there was a recipe for the pork tenderloin puree. [NAME] 7 located the recipe book. The book did not include the recipe for tenderloin puree. The kitchen manager was surprised the recipe did not include puree. He indicated he would locate a recipe and bring it for review along with 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-26 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a sanitary environment for dining in the crown dining room. 20 residents of 108 residents residing in the facility consumed meals in the crown dining room. Findings include: During an observation and interview on 8/21/24 at 1:19 PM, Resident 77 picked up plates, glasses and silverware from tables, placing them in a large dishpan on top of a cart. No gloves were worn, and no hand hygiene was observed. A white fluffy substance was observed on Resident 77's hand, consistent in appearance to the mashed potatoes served at the lunch meal. Resident 77 propelled herself by grabbing the tables where residents were seated. She grabbed the handle on Resident 49's wheelchair and pulled her wheelchair forward. Resident 77's hands still contained remnants of white fluffy residue. She had not utilized had hygiene. [NAME] 8 indicated Resident 77 liked to help, but she was not capable of maintaining sanitation standards. [NAME] 8 indicated she 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-26 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 formulation of an advanced directive after admission for 1 of 1 residents reviewed. (Resident 30) Findings include: Resident 30's record was reviewed on 8/21/24 at 9:40 AM. Diagnoses included respiratory failure, Parkinson's disease, and type 2 diabetes with chronic kidney disease. A review of Resident 30's current quarterly Minimum Data Set (MDS) indicated their Basic Interview for Mental Status (BIMS ) score was 14 (cognitively intact). A review of Resident 30's current care plan, dated 8/14/24, titled Resident and family have chosen a DNR order, indicated Resident 30 would not have life-saving measures performed, and all caregivers would be informed of code status. A review of physician orders dated 8/21/24 at 11:00 AM indicated Resident 30's DNR order was discontinued 8/14/24, and not reinstated until 8/21/24. A review of progress notes dated 8/20/24 indicated Resident 30 declined to decide an advanced directive status upon readmission from hospital on 8/19/24. In an interview on 8/21/24 at 10:30 AM, 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 · D2024-08-26 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to ensure all Minimum Data Set (MDS) sections were completed for 2 of 32 residents reviewed (Resident 76, and Resident 66). Findings include: 1) Resident 76's record was reviewed on 8/23/24 at 1:40 PM. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, major depressive disorder, recurrent severe without psychotic features, and prediabetes. Resident 76's current quarterly MDS dated [DATE] indicated their Basic Interview for Mental Status (BIMS) score was not completed. Each question in the BIMS assessment was answered not assessed. In an interview on 8/26/24 at 8:30 AM, the Director of Therapy indicated the therapy department was responsible for the completion of the MDS section C for all MDS assessments for all residents. He indicated a problem with completion was identified and the department heads began reviewing MDS assessments in the morning meeting each day around two weeks ago. In an…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-26 · 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 interview and record review the facility failed to identify and initiate plans to mitigate trauma informed care for 1 of 1 resident reviewed. (Resident 66) Resident 66's record review began on 8/20/24 at 11:04AM. Diagnoses included heart disease, depression, and Post Traumatic Stress Disorder (PTSD ). Resident 66's Trauma Screening Questionnaire dated 7/30/24, was not completed on admission. Resident 66 did not have a plan of care in place to minimize or alleviate triggers, no PTSD related triggers were identified. Resident 66 had a care plan related to alteration in amount of sleep secondary to insomnia. The insomnia was not identified as a sign or symptom of his PTSD. There were no progress notes to indicate family had collaborated to assist in identifying PTSD triggers. Prior to admission, Resident 66 lived at home with his wife. There were no progress notes to indicate counseling or talk therapy had been attempted. Resident 66's admission Minimum Data Set (MDS) dated [DATE] was not fully completed.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-16 · 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 interview and record review, the facility failed to ensure pain management for 1 of 3 residents experiencing pain reviewed (Resident Q). Findings include: On 4/15/24 at 10:16 A.M., Resident Q was interviewed. She'd had a recent stay at the facility for rehabilitation services following a fracture due to a fall. During her stay, she experienced unrelieved pain. This led to her early discharge from the facility. She indicated she believed her pain worsened during her stay becasue she sat in a chair and on the toilet for long periods of time. This increased the pain in her hip and pelvis. Additionally, she alleged pain medications were not given timely and when administered, were ineffective in relieving the pain. She indicated she had entered the facility on 3/21/24, asked for prescribed pain medication but wasn't given anything until 3:30 a.m. on 3/22/24. She indicated this put her behind with pain management making it difficult to regain control of the pain. She initiated early discharge due to ineffective pain management. On 4/16/24 at 11:44 A.M., Resident Q's record 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-12-22 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
    Provide enough food/fluids to maintain a resident's health.
    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 meal consumption percentage was documented for 4 of 4 residents reviewed (Resident B, Resident D, Resident E and Resident F). Findings include: 1. A record review was completed for Resident B on 12/21/23 at 12:33 PM. Resident B's point of care charting, dated 11/22/23 - 12/20/23 indicated meal consumption percentage was not documented for the following dates and meals: 11/23/23: no lunch or supper documentation 11/24/23: no supper documentation 11/26/23: no breakfast or supper documentation 12/1/23: no supper documentation 12/2/23: no supper documentation 12/3/23: no breakfast documentation; lunch documentation indicated resident was not available 12/4/23: no lunch or supper documentation 12/5/23: no breakfast or supper documentation 12/6/23: no supper documentation 12/8/23: no supper documentation 12/12/23: no supper documentation 12/15/23: no supper documentation 12/16/23: no supper documentation Resident B's progress notes, dated 11/22/23 - 12/20/23, were reviewed. There was no documentation regarding meal…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-12-22 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to ensure sanitation procedures were followed. 108 of 110 residents residening in the facility ate their meals prepared from the kitchen. Findings include: 1. During an observation on 12/21/23 at 9:23 AM, there were 4 pots/pan and 3 baking dishes stacked with moisture visible in between the dishes. In an interview on 12/21/23 at 9:23 AM, [NAME] 4 indicated there shouldn't be moisture between dishes. During a continuous observation on 12/21/23 at 10:56 AM-10:58 AM, Dietary Aide 7 removed plate covers from the dishwasher, stacked the covers then placed the stack in the serving line. The plate covers were still wet. Dietary Aide 7 was observed removing cups from the dishwasher, stacked the cups onto a tray. The cups were observed to still be wet. Dietary Aide 5 grabbed the tray of cups and placed the tray on a cart to transport to another dining room. In a interview on 12/21/23 at 10:57 AM, Dietary aide 5 indicated the cups were still wet. Dietary aide 5 indicated it was okay to use the wet cups to serve in the other…

    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 · E2023-08-08 · 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 date medication when opened in 4 of 4 medication carts reviewed. (400 A cart, 400 B cart, 400 C cart, 300 cart Finding include: During a medication storage observation with LPN 3 (Licensed nurse), on 8/3/2023 at 7:55 AM, on the 400 (A) medication cart the following was observed: A medication of insulin aspart for Resident 23 with no open date. There were 38 units remaining of 250 dispensed. A medication vial of Lantus for Resident 39 with no open date. The vial of medication had ¾ of the vial left remaining. Medications of MiraLAX and Lantus for Resident 54 were observed opened and undated. There were 140 cc (cubic centimeter) of 250 cc remaining in the MiraLAX, and 190 units of 260 units remaining of Lantus. A medication of MiraLAX for Resident 6 was observed open with no open date. During an interview on 8/3/2023 at 7:55 AM, LPN 3, indicated the medications should have open dates, she usually didn't work the cart so she was not sure why…

    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 before2023-08-08 · 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 ensure pain was controlled in 1 of 1 resident reviewed. (Resident 249) Findings include: During an interview and observation, on 8/2/23 at 11:45am, Resident 249 indicated she was in a great deal of pain frequently. Resident 249 indicated the pain medication was able to be given every 6 hours and was not effective for the entire time. Resident 249 indicated the pain medication took the sharpness of the pain away. Resident 249 was observed holding onto her right wrist area and holding her right arm close to her body. No brace or other device was applied. Resident 249 indicated a brace does not help with the pain. Resident 249 indicated the facility did not offer ice, heat, or any other reliefs for the pain. Resident 249 indicated pain was attempted to be controlled by routine and as needed pain medications. Resident 249 indicated she had chronic and acute pain. Resident 249 indicated a pain level of 3 was acceptable to her. Resident 249 indicated her pain was a 6 at the time of the interview. Resident 249…

    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 · D2023-08-08 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    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 denture care and replacement was provided for 1 of 3 residents reviewed (Resident 66). Findings include: In an interview on 8/2/23 at 10:34 AM, Resident 66 indicated her bottom denture was broken. Resident 66 indicated a couple months ago she gave her bottom denture to Social Services. Resident 66 indicated when she followed up with Social Services, they indicated they never received her bottom denture. During an observation on 8/2/23 at 10:34 AM, Resident 66 did not have a bottom denture in her mouth. A record review was completed on 8/2/23 at 2 PM for Resident 66. Diagnosis included gastro-esophageal reflux disease with esophagitis and dysphagia pharyngoesophageal phase. A recent quarterly Minimal Data Set (MDS) Assessment, dated 5/26/23, indicated Resident 66 had a Brief Mental Interview Status (BIMS) score of 15/15 (cognitively intact). A dental note, dated 4/27/23, was provided by the Administrator on 8/7/23 at 9 AM. The note indicated Resident 66 was seen by the Dentist on 4/27/23 at the facility.…

    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

“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 KINGSTON HEALTHCARE — 3 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 54.0-1.0 vs chain
Health inspection 2 of 53.3-1.3 vs chain
Staffing 3 of 52.7+0.3 vs chain
Quality measures 5 of 54.7+0.3 vs chain
The other 2 homes this chain runs (chain average 4.0★, 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
HOLIFIELD, ALICIAIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/14/2026
JAROSINSKI, STEPHENIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2022
MALOTT, GREGGIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 10/01/2015
OFFERLE, ANDREWIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 12/16/2025
KINGSTON CARE CENTER OF FORT WAYNE, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2015
PARAGON OUTPATIENT REHABILITATION SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/16/2025
PULASKI MEMORIAL HOSPITALOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 12/16/2025
TRILOGY HEALTHCARE OF WASHINGTON CENTER LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 12/16/2025
BARNEY, LEIGHIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/14/2026
DAVIS, DAVIDIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/13/2026
BENNETT, ADAMIndividualTRUSTEE OF THE SNFsince 12/16/2025
HUTTON, CHARLESIndividualTRUSTEE OF THE SNFsince 12/16/2025
KAUFFMAN, CLINTONIndividualTRUSTEE OF THE SNFsince 12/16/2025
MCKAY, MICHAELIndividualTRUSTEE OF THE SNFsince 12/16/2025
MELLON, JENNIFERIndividualTRUSTEE OF THE SNFsince 12/16/2025
SMITH, JENNIFERIndividualTRUSTEE OF THE SNFsince 12/16/2025
WHITE, TAYLORIndividualTRUSTEE OF THE SNFsince 12/16/2025
AMERICAN HEALTHCARE REIT HOLDINGS LPOrganizationADP OF THE SNFsince 12/16/2025
AMERICAN HEALTHCARE REIT INCOrganizationADP OF THE SNFsince 12/16/2025
CONTINENTAL MERGER SUB LLCOrganizationADP OF THE SNFsince 12/16/2025
GAHC3 TRILOGY JV LLCOrganizationADP OF THE SNFsince 12/16/2025
TRILOGY HEALTHCARE HOLDINGS, INC.OrganizationADP OF THE SNFsince 12/16/2025
TRILOGY INVESTORS LLCOrganizationADP OF THE SNFsince 12/16/2025
TRILOGY MANAGEMENT SERVICES LLCOrganizationADP OF THE SNFsince 12/16/2025
TRILOGY OPCO LLCOrganizationADP OF THE SNFsince 12/16/2025
TRILOGY PRO SERVICES LLCOrganizationADP OF THE SNFsince 12/15/2025
TRILOGY PROPCO II LLCOrganizationADP OF THE SNFsince 12/16/2025
TRILOGY PROPERTY HOLDINGS LLCOrganizationADP OF THE SNFsince 12/16/2025
TRILOGY REAL ESTATE INVESTMENT TRUSTOrganizationADP OF THE SNFsince 12/16/2025
TRILOGY REAL ESTATE WASHINGTON CENTER LLCOrganizationADP OF THE SNFsince 12/16/2025
TRILOGY REIT HOLDINGS LLCOrganizationADP OF THE SNFsince 12/16/2025

CMS files one row per role, so the 37 rows in the source record cover these 31 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.

18 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.

$15.6M
Net patient revenuemost recent cost report
-5.4%
Operating marginrevenue minus expenses
$939K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 48%Medicare 14%Other / private 38%

This home reported $939K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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

$416per resident / day
operating cost
$12,652per month
≈ monthly operating cost
$395per 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 155479. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-25, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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