Majestic Care Of Jefferson Pointe
5700 Wilkie Dr, Fort Wayne, IN 46804 · For profit - Corporation · 135 certified beds · (260) 432-7556 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Mar 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — 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
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (57%) runs well above the national median (45%)
- about 23% 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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 1 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 5.4% | 11.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.2% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 1.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 31.5% | 25.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 7.6% | 3.9% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 3.3% | 11.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 20.7% | 23.5% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.0% | 3.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 26.7% | 23.3% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 12.4% | 13.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.1% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 67.6% | 79.0% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 29.8% | 22.2% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 6.7% | 10.8% | 12.0% | better |
‡ 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.
Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 30% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 7% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.6%CMS range 7.5–14.9 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 90.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | not 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.1%CMS range 4.3–16.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.20 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 135 beds and averages 84.5 residents a day — about 63% occupied, or roughly 50 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.56 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.43 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 2.93 hrs/resident/day on weekends vs 3.82 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.37 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 57% is well above 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
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
27 citations, most serious first. The 13 most serious are shown; the remaining 14 are one tap away and print in full.
- Immediate jeopardy · Jcited before2026-05-20 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 observation, interview, and record review, the facility failed to ensure a resident was adequately assessed and provider orders were followed after a change in condition for 1 of 3 residents reviewed. The facility failed to ensure bowel assessments were performed and an abdominal X-ray was completed as ordered. This resulted in the facility sending the resident to the hospital with a perforated bowel (Resident C).The Immediate Jeopardy began on 5/15/26 when the facility failed to assess Resident C's change of condition and complete an order for a follow-up x-ray. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on May 19, 2026, at 4:12 P.M. The immediate jeopardy was removed on 5/20/26 but noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy.Findings include: On 5/18/26 at 9:50 A.M., Resident C was observed seated in a recliner chair with his feet elevated, in the lounge area of the secured memory care unit (MCU). His eyes were closed 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.
- Actual harm · G2026-03-23 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide 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 appropriate weight management interventions were implemented, including follow-up for identified weight loss and notification of the physician regarding significant weight changes for 2 of 3 residents reviewed (Resident 11 and Resident 50). This resulted in severe unintended resident weight loss for Resident 11 and Resident 50. Findings include:1. Resident 11's record was reviewed on 3/17/2026 at 11:55 AM. Diagnoses included dehydration, urinary tract infection (UTI), acute kidney failure and severe sepsis without septic shock.A review of Resident 11's weights indicated on 2/10/26, Resident 11 weighed 110 pounds. On 2/16/2026, Resident 11 weighed 110.0 pounds. On 2/17/2926 Resident 11 weighed 103 pounds, a loss of 7 pounds and 6.3%. On 2/25/2026, Resident 11 weighed 103 pounds. On 3/2/2026, Resident 11 weighed 104 pounds. On 3/9/2026, Resident 11 weighed 102.2 pounds, an additional loss of 1.8 pounds for a total loss of 8.8 pounds or 7.26% in 1 month.The facility could provide no documentation to indicate the severe…
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.
- Actual harm · G2024-02-14 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 residents were free from significant medication errors for 2 of 4 residents reviewed for medication errors. The deficient practice resulted in Resident B experiencing altered mental status that required emergent treatment at the facility for opioid overdose and hospitalization for chest pain. The deficient practice resulted in Resident C experiencing altered mental status with lethargy that required hospitalization. (Resident B, Resident C). 1. An Indiana Department of Health (IDOH) facility-reported incident report was provided by the Administrator on 2/13/24 at 1:00 P.M. The report indicated Resident B had returned from the pain management clinic on 1/19/24 with a new medication order for Suboxone 2.0-0.5 milligram one tablet SL every eight hours for pain. The report indicated the Assistant Director of Nursing (ADON) entered the new order into the electronic medication administration record (EMAR). The report indicated the correct amount 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.
- Potential for harm · Ecited before2026-03-23 · tag F0602 — failed to protect residents from theft of their belongings — patternProtect each resident from the wrongful use of the resident's belongings or money.
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 resident pain medication was secured to prevent misappropriation for 4 of 16 residents reviewed. (Resident 2, Resident 53, Resident 64, and Resident 92)Findings include: 1) Resident 2's record review began on 3/20/26 at 10:06am. Resident 2's diagnosis included necrotizing fasciitis, end stage renal disease, and heart disease. Resident 2's physician order, dated 2/25/26, indicated to give oxycodone 10mg one tablet every 6 hours for pain management. A review of Resident 2's March Medication Administration Record (MAR) compared with his controlled count sheet determined the following dates and times Oxycodone 10mg tabs were taken from Resident 2's controlled substance supply and not documented on the MAR or progress notes as administered to Resident 2:3/2/26 at 7:30 (am or pm was not specified)3/3/26 at 8:10 (am or pm was not specified)3/4/26 at 8:30 (am or pm was not specified)3/6/26 at 7:35 (am or pm was not specified)3/7/26 at 8:15 (am or pm was not specified)3/7/26 at 11:27 (am or pm was not specified)3/8/26 at 8:35…
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.
- Potential for harm · E2026-03-23 · tag F0697 — failed to manage pain — patternProvide 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 provide nonpharmacological interventions to 4 of 4 residents reviewed. (Resident 1, Resident 2, Resident 64, and Resident 92)Findings include: 1) In an interview, on [DATE] at 9:59 AM, Resident 1 indicated the facility only provided medication for pain management. Resident 1 indicated knowledge massages could be helpful from use in physical therapy. Resident denied any massages, ice, or other non-pharmacological interventions were given prior to as needed pain medication administration. Resident 1's record was reviewed [DATE] at 9:16 AM. Diagnosis included heart disease, lung disease, and depression. Resident 1's physician order, dated [DATE], indicated to give oxycodone-Acetaminophen 5-325mg 1 tablet by mouth every 4 hours as needed for pain. Resident 1's [DATE] Medication Administration Record (MAR) indicated he received the pain medication without any documentation of non-pharmacological interventions in the MAR as follows:[DATE] at 7:11pm[DATE] 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.
- Potential for harm · D2026-03-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 neurological evaluation was completed after a blow to the eye for 1 of 3 residents reviewed. (Resident 55)Findings Include:A progress note, dated 3/10/2026 at 10:19 PM, indicated Resident 55 was sitting on their bed. The progress note indicated Resident 55 stated another resident hit him near his eye and upon assessment, Resident 55 was noted to have bruising to their left eye and a scratch under his right eye.A progress note dated 3/11/2026 at 5:18 PM, indicated the Interdisciplinary Team (IDT) met to review the incident on 3/10/2026 around 10 PM. The progress note indicated Resident 55 was in his room sitting on his bed when a nurse was called to the unit, as another resident had made contact with Resident 55 in the face.A 15-minute check on 3/13/2026 at 10:50 AM indicated Resident 55 was resting in bed with left eye bruising/swelling.A 15-minute charting on 3/15/2026 at 11:50 AM indicated Resident 55's bruising continued to heal.A 15-minute charting on 3/16/2026 at 1:02 PM indicated Resident 55's bruising…
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.
- Potential for harm · Dcited before2026-03-23 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to destroy a deceased resident's controlled substance in a timely manner for 1 of 1 resident reviewed. (Resident 92)Findings include: Resident 92's record review began on [DATE] at 2:10 PM. Diagnosis included end stage renal disease, diabetes, and heart disease.Progress notes confirmed Resident 92's respiration had ceased on [DATE] at 10:53am.Resident 92's controlled count sheet for hydromorphone (Dilaudid) 4mg tablets indicated a tablet was signed out at 1:00pm, 5:00pm, and 9:00pm on [DATE]. After Resident 92 was no longer alive. Licensed Practical Nurse (LPN)11's time card verified she did not work on [DATE]. Her initials were documented on [DATE] at the times 1:00pm, 5:00pm, and 9:00pm indicated on the controlled count sheet for hydromorphone (DIlaudid) 4mg tablets.Resident 92's controlled count sheet for hydromorphone 4mg tablets entries dated [DATE] at 1:00pm, 5:00pm, and 9:00pm were not questioned until [DATE]-5 days later. These medications were…
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.
- Potential for harm · D2026-02-05 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 for wound treatment were completed for 1 of 2 residents reviewed with pressure ulcers (Resident E). Findings include:On 2/4/26 at 11:36 A.M., Resident E's record was reviewed. Diagnoses included schizophrenia, dementia, anxiety disorder, and hip fracture.A significant change Minimum Data Set (MDS) assessment, dated 1/6/26, indicated a Brief Interview Mental Status (BIMS) of 9 indicating Resident E had moderately impaired cognition with delusions. She had 1 unstageable pressure ulcer and 2 unstageable pressure injuries.A care plan, dated 1/16/26, indicated Resident E had been re-admitted to the facility with an unstageable pressure ulcer to her sacrum/coccyx. Interventions included providing wound treatment as ordered.A physician order, dated 1/14/26, indicated to administer Dakins (1/4 strength) External Solution 0.125% (Sodium Hypochlorite)- Apply to coccyx every shift. Cleanse coccyx with Dakins dampened Kerlix, apply Therahoney to the sacrum and cover with Mepilex dressing.A Medication…
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.
- Potential for harm · Dcited before2025-11-24 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
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 were free from exploitation related to personal funds for 1 of 1 resident reviewed (Resident E).Findings include:On 11/24/25 at 1:10 P.M., Resident E's record was reviewed. Diagnoses included diabetes, anxiety, and depression.A quarterly Minimum Data Set (MDS) assessment, dated 10/21/25, indicated Resident E was cognitively intact and able to make decisions.A Report of Concern, dated 10/12/25, indicated Resident E reported, Certified Nurse Aide (CNA) 5 had asked him to lend her money about 1 month prior. CNA 5 indicated she was short on funds and needed the money to pay bills. Resident E loaned her 400 dollars with the agreement the CNA would pay back. Since giving her the money, CNA 5 avoided him and didn't pay back any money.An investigation of the concern indicated CNA 5 was placed on suspension. While suspended, CNA 5 refused to take calls or be part of the investigation. An undated written note from CNA 5 to Resident E, indicated the CNA just got her paycheck, the check wouldn't cover bills due 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.
- Potential for harm · D2025-10-16 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
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 opportunities to participate in the care planning process and inclusion in decisions about care and treatment for 1 of 3 residents reviewed for resident rights (Resident H). Findings include:A report, dated 10/1/25 at 10:30 a.m., alleged Resident H had been verbally and physically abused by Licensed Practical Nurse (LPN) 2. He alleged LPN 2 refused to let him have things his care plan indicated he was allowed. Resident H reported this to the Administrator and the Ombudsman. Resident H was allegedly told LPN 2 would no longer be assigned to care for him. The resident alleged he was being retaliated against for filing a police report against LPN 2 and the facility for alleged neglect. The report alleged someone from another facility, in another town, an hour from the current one, came to see the resident to assess him for possible discharge to their facility. Resident H had not requested nor given permission to be assessed by the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-10-16 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 an allegation of physical abuse was reported timely for 1 of 3 residents reviewed for abuse (Resident H). Findings include:A report, dated 9/23/25 at 6:53 p.m., indicated Resident H alleged Licensed Practical Nurse (LPN) 2 struck him on his hand after the resident allegedly kicked LPN 2. A Certified Nurse Aide had been present during the incident and indicated they witnessed Resident H kick LPN 2 but hadn't seen LPN 2 strike the resident on the hand. A nurse progress note, dated 9/20/25 at 10:44 p.m., indicated Resident H became upset with LPN 2 over a physician order he hadn't agreed with. The resident became verbally aggressive and allegedly kicked LPN 2 in the face. Staff left the room to allow Resident H to calm down. After staff left the room, a police officer showed up at the facility after a 911 call, placed by Resident H, who alleged LPN 2 had struck him on the hand.On 10/16/25 at 10:35 A.M., the Administrator was interviewed. He indicated he had been notified of the incident on 9/20/25 (unknown time) but…
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.
- Potential for harm · D2025-10-16 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 thoroughly investigate an allegation of abuse and ensure measures were in place to prevent further abuse while the investigation was in process for 1 of 3 residents reviewed for abuse (Resident H).Findings include:A report, dated 10/1/25 at 10:30 a.m., alleged Resident H had been verbally and physically abused by Licensed Practical Nurse (LPN) 2. He alleged LPN 2 refused to let him have things his care plan indicated he was allowed and alleged she had smacked his hand. LPN 2 continued to work with him and on his unit despite his request to have her removed from his care. Resident H alleged LPN 2 was retaliating against him due to a police report he had filed against her. The alleged retaliation included delays in his call light being answered after being soiled, refusals to provide him with alcohol allowed per his care plan, and being hung up on by LPN 2 when trying to reach staff by phone, to answer his call light. On 10/14/25 at 2:00 P.M., Resident H was observed in his room. He lay in bed and had several…
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.
- Potential for harm · F2025-04-10 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, and interview, the facility failed to ensure the daily report of nursing staff directly responsible for resident care was accurately posted. This had the potential to effect 74 of 74 residents. Findings include: During an observation, on 4/6/25 at 9:01 AM, next to the front desk on the wall, visible to all. There was a plastic slot with several daily staffing postings inside. The date of the visible sheet was 4/3/25. The daily posting behind was dated for 4/2/25. The third one was dated 3/28/25. The last one was dated 3/6/25. There were several staff members observed to pass by the daily postings. In an interview, on 4/6/25 at 9:15 AM, the Maintenance Director indicated, he was not sure who was supposed to change the daily posts, he thought it might be the receptionist changed them every day she worked. The manager on duty was Medical Records. In an interview, on 4/6/25 at 9:31 AM, Medical Records indicated the scheduler changed the daily posting every day, she was inthe building and would be asked to change the staffing posting. In an interview, on 4/6/25 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.
Show the remaining 14 citations
- Potential for harm · Ecited before2025-04-10 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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, record review, and interview, the facility failed to maintian sanitary conditions related to kitchen equipment, hand hygiene while serving a meal, and use proper labeling. 74 of 74 residents who resided in the facility ate food received from kitchen. Findings include: During an initial observation of the kitchen on 4/6/25 at 9:00 AM, the following was observed: At the handwashing sink, inside was brown and yellow food debris. The paper towel dispenser was broken at handwashing sink. No paper towels were avilable to dry staff hands. In the dry storage, there was a cardboard box of thicker open to air. On the kitchen floor, there were spills of red and yellow liquid. terry cloth Towels were observed on the floor. The floor was greasy, visible, were large and small debris of white, black and grey pieces of food on the ground. Inside the walk-in refrigerator, there was a metal can of mustard opened with seran wrap covering the entire open top. There were 3 containers of brown liquid with no…
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.
- Potential for harm · D2025-04-10 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview the facility failed to ensure dignity was mainatined for 1 of 18 residents reviewed. (Resident 38) Findings include: During an observation, on 4/7/25 at 12:33 PM, in the dinning room on the men's memory unit, Certified Nursing Assistant (CNA) 2 was heard yelling from Resident 38's room. CNA 2 yelled down to other staff, I need a brief, pants, linens, and towels. I just don't want him walking down the hall. In an interview, on 4/7/25 at 12:50 PM, CNA 2 indicated I should have waved someone down to me. I was thinking safety over dignity. I didn't even think to use the call light. Yelling down the hall is a dignity issue. Resident 38's record review began on 4/8/25 at 8:47 AM. Diagonsis included Alzheimer's diease, unspecified. A current policy, titled Dignity dated 12/12/2024, indicated . 10. Speak respectfully to residents; avoid discussions about residents that may be overheard .12. Maintain resident privacy . 3.1-3(a)
- Potential for harm · Dcited before2024-12-04 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure medications were available for resident use as directed by the physician for 1 of 1 residents reviewed. (Resident S) Findings include: In an interview on 12/4/24 at 9:05 AM, LPN 2 indicated when staff administered medications, they were to check the 5 rights of the resident to prevent medication errors. She indicated when a medication was not available staff were to call the pharmacy and get authorization to use the onsite medication dispensing machine. If the machine did not have the medication, the physician and family were to be notified for further direction. In an interview on 12/4/2024 at 2:10 PM, Resident S indicated the medication he was prescribed for weight loss (Ozempic) was not being given. Resident S indicated medication was to start in August, but had not been given as directed because the facility would not obtain the medication for him. Resident S's record review began on 12/4/24 at 3:58 PM. Diagnoses included diabetes and morbid obesity. Resident S's Physicians orders dated 8/8/24 indicated to give…
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.
- Potential for harm · D2024-05-24 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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
Based on interview and record review, the facility failed to ensure a resident was treated with respect and dignity for 1 of 3 residents reviewed. (Resident F) Findings include: A record review began on 5/22/24 at 10:30 AM of an incident that occurred between Resident F and Certified Nurses Aide 6 (CNA). On 4/18/24, no time specified, CNA 6 was observed having a disagreement with Resident F. Resident F was also on the phone with a family member at the time. CNA 6, heard the resident mention something regarding CNA 6 to the family member. Then CNA 6 put their middle finger up and gestured toward the resident. The immediate action from facility: CNA 6 was immediately suspended pending investigation. Physician, Pysch services, and family were notified. On 5/22/24 at 10:45 AM, Resident F's record was reviewed. Diagnoses included, Chronic Obstructive Pulmonary disease with acute exacerbation. A quarterly MDS (Minimum Data Set) assessment, dated 4/12/24, brief mental status interview indicated Resident F had no cognitive impairment. In an interview on 05/22/24 at 2:08 PM, Resident F…
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.
- Potential for harm · D2024-05-24 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure labeling of open date for 1 of 3 carts reviewed affecting 3 residents. (Resident 9, Resident 14, Resident 92). Findings include: During an observation with interview on 05/21/24 at 9:33 AM on [NAME] Hall with QMA 3 (Qualified Medical Assistant), the medication room and medication cart was well labeled. QMA 3 indicated all meds were to be labeled with an open date when opened and a discard or expiration date. During an observation with interview on 05/22/24 at 01:12 PM in the East Hall medication room and medication cart. The East Hall cart had three opened medications without an open date. The medications were as follows: Resident 9 cough syrup liquid the silver seal was punctured. Resident 14 polyethylene glycol powder the seal was removed; about a half a bottle remained. Resident 92 milk of magnesia the seal was removed. QMA 4 was labeling Resident 14's and Resident 92's medication bottles with the date 5/15/24. QMA 4 indicated one of the 2 residents was a recent admit and she was aware 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.
- Potential for harm · D2024-02-14 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 interview and record review the facility failed to ensure residents were free from verbal abuse for 1 of 6 residents reviewed (Resident F). Findings include: A facility reported incident was provided by the Administrator on 2/13/24 at 1 PM. The report indicated Resident F had reported to the staff about an incident with Licensed Practical Nurse 3. The report indicated on 1/22/24, LPN 3 had made the comment you mean, miserable man - people like you in my country, we cut their heads off. An investigation file was provided by the Administrator on 2/14/24 at 11:30 AM. The filed statements indicated the following: - Dated 1/23/24 by Resident F indicated on 1/22/24 LPN 3 had assisted with setting up Resident F's breathing treatment and LPN 3 had knocked a few things off the resident's night stand. The statement indicated Resident F stated to LPN 3 you just don't know what you are doing, do you? LPN 3 responded Im African, people like you get their heads cut off in my country. - Dated 1/29/24 by LPN 3 indicated on 1/22/24 LPN 3 while setting up Resident F's breathing treatment,…
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.
- Potential for harm · Ecited before2024-01-17 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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, interview, and record review the facility failed to ensure safe food handling, serving temperatures, and storage. 87 residents resided in the facility. Findings include: 1. During an observation on, 1/17/24 at 8:06AM, gnats were flying around near the dish washing sink and food serving island. There was a moderate amount of food debris around the serving island. Under the island there were crumbs noted. The crumbs varied in size, consistency, and color (yellow, brown, and black) The two smaller trash cans did not have liners present. The one closest to the serving island had debris visualized inside. Observed built up black residue in all corners of the floor under cabinets, the serving island, and in the corners of the rooms. In an interview on 1/17/24 at 8:15AM, the Dietary Manager (DM), indicated the gnats had been a problem for around 6 weeks. She indicated she spoke with her supervisor, the Dietician, and was told to speak with the facilities maintenance director. The DM indicated she…
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.
- Potential for harm · Dcited before2023-10-27 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure timely physician notification for 1 of 3 residents reviewed. (Resident B) Findings include: An event reported by the facility to the Indiana Department of Health indicated there was a concern for a resident who had inflicted self-injuries with a razor. In an interview on 10/27/23 at 10:25 AM the Administrator indicated Resident B had self-injured their left arm with a razor. The Administrator indicated they were unaware of how the resident had obtained a razor. Resident B's record was reviewed on 10/27/23 at 10:50 AM. Diagnoses included schizoaffective disorder, bipolar disorder, alcohol dependence, nicotine dependence, major depressive disorder, generalized anxiety disorder, non-Alzheimer's dementia, insomnia, other unspecified behavioral disturbances and impulse disorder. Resident B's current comprehensive Minimum Data Set (MDS) dated [DATE] indicated their Basic Interview for Mental Status (BIMS) score was 9 (moderate cognitive impairment).…
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.
- Potential for harm · D2023-10-27 · tag F0699 — isolatedProvide 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 ensure the recognition provision of trauma informed care for 1 of # 3 residents reviewed. (Resident B) Findings include: An event reported by the facility to the Indiana Department of Health indicated there was a concern for a resident who had inflicted self-injuries with a razor. Resident B's record was reviewed on 10/27/23 at 10:50 AM. Diagnoses included schizoaffective disorder, bipolar disorder, alcohol dependence, nicotine dependence, major depressive disorder, generalized anxiety disorder, non-Alzheimer's dementia, insomnia, other unspecified behavioral disturbances and impulse disorder. Resident B's current comprehensive Minimum Data Set (MDS) dated [DATE] indicated their Basic Interview for Mental Status (BIMS) score was 9 (moderate cognitive impairment). The MDS indicated the resident felt hopeless or depressed, had trouble sleeping, felt tired with minimal energy, felt restless, moved slowly and spoke slowly nearly every day. Resident B's…
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.
- Potential for harm · D2023-10-27 · tag F0742 — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
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 assess and track behavior for 1 of 3 residents reviewed. (Resident B) Findings include: An event reported by the facility to the Indiana Department of Health indicated there was a concern for a resident who had inflicted self-injuries with a razor. In an interview on 10/27/23 at 10:25 AM the Administrator indicated Resident B had self-injured their left arm with a razor. The Administrator indicated they were unaware of how the resident had obtained a razor. Resident B's record was reviewed on 10/27/23 at 10:50 AM. Diagnoses included schizoaffective disorder, bipolar disorder, alcohol dependence, nicotine dependence, major depressive disorder, generalized anxiety disorder, non-Alzheimer's dementia, insomnia, other unspecified behavioral disturbances and impulse disorder. Resident B's current comprehensive Minimum Data Set (MDS) dated [DATE] indicated their Basic Interview for Mental Status (BIMS) score was 9 (moderate cognitive impairment). The MDS…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-27 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
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 the provision medically related Social Services for 1 of 3 residents reviewed. (Resident B) Findings include: An event reported by the facility to the Indiana Department of Health indicated there was a concern for a resident who had inflicted self-injuries with a razor. In an interview on 10/27/23 at 10:25 AM the Administrator indicated Resident B had self-injured their left arm with a razor. The Administrator indicated they were unaware of how the resident had obtained a razor. Resident B's record was reviewed on 10/27/23 at 10:50 AM. Diagnoses included schizoaffective disorder, bipolar disorder, alcohol dependence, nicotine dependence, major depressive disorder, generalized anxiety disorder, non-Alzheimer's dementia, insomnia, other unspecified behavioral disturbances and impulse disorder. Resident B's current comprehensive Minimum Data Set (MDS) dated [DATE] indicated their Basic Interview for Mental Status (BIMS) score was 9 (moderate…
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.
- Potential for harm · Dcited before2023-10-03 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 ensure staff reported an allegation of abuse immediately to the facility administrator for 1 of 4 allegations of abuse reviewed. (Resident F) Findings include. On 9/27/2023 at 3:50 P.M., the Administrator provided State Reportable Incidents for September 2023. On 9/28/2023 at 9:40 A.M., the facility reported reviewed indicated the incident date was 09/04/2023 at 4:59 AM, and involved Resident F and CNA (Certified Nurse Aide) 2. The report indicated the Administrator had filed the report with Indiana Department of Health (IDOH) on 9/5/2023. The Description of the Incident indicated CNA 2 alleged she was walking by the room of a resident whose door was closed and thought she overheard the resident saying, Don't hit me. The report indicated Resident F's baseline was nonsensical speech. CNA 2 entered the room to see if she could help. The report indicated Resident F had no complaints of pain and no new injuries when assessed on 9/5/2023. Psychosocial…
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.
- Potential for harm · D2023-10-03 · tag F0728 — failed to protect against nurse-aide misconduct — isolatedEnsure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a CNA (Certified Nurse Aide)worked in the facility was certified within 120 days of completion of training. (CNA 8) Findings include: In an interview on 9/28/2023 at 11:15 A.M., Resident D indicated he had fallen because his legs just gave out. When asked if the call light was on when he fell, he indicated it was not. He indicated he had used the call light and it worked. CNA 8 had turned off the call light and didn't come back. Resident D indicated he was not hurt when he fell and did not feel abused or neglected. Resident D indicated he had not reported the fall to anyone. Resident D agreed to report to the Administrator. In an interview on 9/28/2023, At 11:30 A.M., the Administrator, reported CNA 8 had been educated by the ADON (Assistant Director of Nursing) about answering call lights, completing care, and to not turn off the call light when the care was not completed. The Administrator indicated he would check with the ADON and if she would…
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.
- Potential for harm · E2023-08-09 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to maintain a clean environment for 7 of 10 residents reviewed (Resident C, Resident E, Resident F, Resident H, Resident I, Resident J, Resident K). Findings include: On 8/9/23 at 10:52 AM the Administrator indicated Resident C, Resident H, Resident I, and Resident K were interviewable. 1. During an observation on 8/9/23 at 10:07 AM, Resident C pulled an overflowed trash can out of the activity room into the hallway. In an interview on 8/9/23 at 10:07 AM, Resident C indicated he pulled the overflowed trash can out into the hallway so someone would see it and empty it. Resident C indicated the trash cans in the common areas tend to overflow more than the ones in the residents' rooms. 2. During an observation on 8/9/23 at 10:25 AM, Resident H's trash can was overflowing with trash. In an interview on 8/9/23 at 10:25 AM, Resident H indicated his trash can had not been emptied for 1-2 days and he had requested staff to empty it. 3. In an interview on 8/9/23 at 10:29 AM, Resident I indicated there was been dried bowel…
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.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to MAJESTIC CARE — 22 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.5 | -1.5 vs chain |
| Health inspection | 1 of 5 | 2.1 | -1.1 vs chain |
| Staffing | 1 of 5 | 1.7 | -0.7 vs chain |
| Quality measures | 3 of 5 | 4.5 | -1.5 vs chain |
The other 21 homes this chain runs (chain average 2.5★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PULASKI MEMORIAL HOSPITAL | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 12/31/2020 |
| CHAISSON, PAUL | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 12/31/2020 |
| MALOTT, GREGG | Individual | CORPORATE OFFICER | — | since 12/31/2020 |
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 80% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.7M paid to related parties — landlords or management companies under common ownership — equal to about 23% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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
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.
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 155446. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-23, 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.