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Clinton House Rehabilitation And Healthcare Center

809 W Freeman St, Frankfort, IN 46041 · For profit - Corporation · 88 certified beds · (765) 654-8783 Medicare & Medicaid certified

Call the home — (765) 654-8783 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citations — no harm found (F0744, F0758)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
Worth asking about
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)
  • about 19% of its spending goes to commonly-owned related companies

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

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

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1300 S Jackson St · (765) 656-3900 · Call to confirm hours
Pharmacy
359 W Walnut St · (765) 654-4300 · Call to confirm hours
Grocery
256 W Armstrong St · (765) 659-0603 · Call to confirm hours
Park
1080 S 3rd St · Typically dawn to dusk
Place of worship
1058 W Freeman St · (317) 650-8478

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 5 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 rating5★
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 increased2.5%11.0%15.4%better
Long-stay residents who lose too much weight5.3%5.5%5.4%typical
Long-stay residents with a catheter left in their bladder0.4%0.4%0.9%typical for the state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.2%1.1%2.0%better
Long-stay residents with depressive symptoms16.7%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 injury1.2%3.9%3.3%better
Long-stay residents whose ability to walk worsened3.3%11.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication19.2%23.5%18.9%typical
Long-stay residents given the seasonal flu vaccine97.5%95.4%95.3%typical
Long-stay residents with pressure ulcers2.5%3.6%4.7%better
Long-stay residents with worsening bladder/bowel control21.0%23.3%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table19.9%13.6%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine82.9%79.0%79.4%typical
Long-stay hospitalizations per 1,000 resident days1.361.611.67better
Long-stay outpatient ER visits per 1,000 resident days2.021.441.80worse

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.

10.9%U.S. median 10.7%
Went back to hospital
0.17U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.17 therapist hours per resident per day in 2026Q1 — more than 17% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% 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 SNFnot 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 SNF10.9%CMS range 7.0–16.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot 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 dischargenot 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 dischargenot 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 identified90.9%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened9.1%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 hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.521.02Oct 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

0.48
RN hours/ resident / day
0.73
LPN hours/ resident / day
1.80
Aide hours/ resident / day
3.01
Total nurse hours/ resident / day
0.35
RN hoursweekends
44.6%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 88 beds and averages 69.9 residents a day — about 79% occupied, or roughly 18 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.01 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.80 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 2.72 hrs/resident/day on weekends vs 3.13 on weekdays — 13% thinner on weekends. RN hours go from 0.54 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 45% is about the same as 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

6
deficiencies at the latest standard inspection (2025-08-15)
7
at the previous standard inspection (2024-09-10)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.

  • Potential for harm · D2025-08-15 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    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 comprehensive Minimum Data Set (MDS) assessment was completed within 14 days of admission for 1 of 4 residents reviewed for MDS assessments. (Resident 12)Finding includes:The clinical record for Resident 12 was reviewed on 8/11/25 at 2:42 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), dementia, and congestive heart failure.Resident 12 had an entry MDS assessment completed on 6/30/25.An admission MDS assessment, with an Assessment Reference Date (ARD) date of 7/13/25, was still in progress and was not completed as of 8/12/25.During an interview, on 8/12/25 at 2:42 p.m., the MDS Coordinator indicated the admission comprehensive MDS assessment was overdue by 30 days. The assessment should have been completed by 7/13/25.During an interview, on 8/12/25 at 2:45 p.m., the MDS Coordinator indicated the facility followed the Resident Assessment Instrument (RAI) manual for their policy.An RAI manual, titled Long-Term Care Facility Resident Assessment Instrument 3.0 User'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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-15 · tag F0638 — isolated
    Assure that each resident’s assessment is updated at least once every 3 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure quarterly Minimum Data Set (MDS) assessments were completed every 3 months for 3 of 4 residents reviewed for MDS assessments. (Resident 17, 30, and 59)Findings include:1. The clinical record for Resident 17 was reviewed on 8/11/25 at 3:15 p.m. The diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, type 2 diabetes mellitus, moderate vascular dementia with psychotic and mood disturbance, and anxiety disorder.The first quarterly assessment after the annual comprehensive Minimum Data Set (MDS) assessment for Resident 17 was completed on 4/6/25. The next quarterly assessment was completed 4 months later (127 days), on 8/11/25.2. The clinical record for Resident 30 was reviewed on 8/11/25 at 3:20 p.m. The diagnoses included, but were not limited to, hydrocephalus, paraplegia, and mild dementia with mood disturbance.The first quarterly assessment after the annual comprehensive Minimum Data Set (MDS) assessment for Resident 30 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-15 · 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 the physician was notified of high blood glucose levels within the physician's ordered call parameters for 1 of 1 resident reviewed for quality of care. (Resident 53)Findings include: The clinical record for Resident 53 was reviewed on 8/11/25 at 2:00 p.m. The diagnoses included, but were not limited to, morbid obesity, type 2 diabetes, and hypertension.A physician's order, dated 7/22/25, indicated to give Admelog injection (insulin lispro) per sliding scale. If the blood glucose was 401 or more, give 9 units and call the Medical Doctor (MD).The following blood glucose readings were over 401 with no documentation the MD was called:a. On 7/23/25 at 11:29 a.m., the blood glucose reading was 496 with no documentation the MD was called.b. On 7/31/25 at 4:40 p.m., the blood glucose reading was 401 with no documentation the MD was called.c. On 8/6/25 at 9:18 p.m., the blood glucose reading was 417 with no documentation the MD was called.d. On 8/7/25 at 8:43 p.m., the blood glucose reading was 416 with no documentation 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-15 · tag F0727 — failed to provide required RN coverage — isolated
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled for at least 8 consecutive hours 7 days a week for 2 of 21 days reviewed for staffing. (7/20/25 and 8/3/25)Findings include:The as worked staffing schedules were reviewed on 8/11/25 at 1:35 p.m. A RN was not scheduled to work on Sunday, 7/20/25. A RN was not scheduled to work on Sunday, 8/3/25. The facility assessment, dated 3/17/25, indicated the facility had 2 residents who required IV (Intravenous) medications on average. Staff with specialized training such as RNs were to be assigned to areas with residents with higher acuity needs.During an interview, on 8/15/25 at 10:19 a.m., the Director of Nursing indicated there was no RN present in the facility on 7/20/25 and 8/3/25. The facility followed the CMS guidelines for staffing, and an RN should have been present on those dates for at least 8 consecutive hours.The facility did not provide a staffing policy prior to exit. 3.1-17(b)(3)

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-15 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure PPE (personal protective equipment) was worn correctly and to establish a clean field for wound care supplies for 1 of 6 residents reviewed for infection control. (Resident 21)Finding includes:During an observation, on 8/14/25 at 9:32 a.m., Unit Manager (UM) 2 gathered wound care supplies, which included, an antiseptic wound cleanser, gauze pads, calcium alginate with silver (an antimicrobial dressing), and a foam bordered dressing, in preparation to perform a wound care treatment for Resident 21. After gathering the wound care supplies, UM 2 then put on PPE (a gown and gloves). UM 2 did not tie the gown closed around her waist. UM 2 then placed the wound care supplies on Resident 21's bedside table and opened them. UM 2 was not observed to have cleaned the surface of the bedside table prior to placing the wound care supplies on the table and opening them. The wound care supplies were observed to have been placed on the bedside table next to a urinal with approximately 200 milliliters of urine in it.…

    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 · D2024-09-10 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure baseline care plans were completed within 48 hours after admission for 2 of 2 residents reviewed for baseline care plans. (Resident B and 34) Findings include: 1. During an observation, on 9/3/24 at 10:51 a.m., Resident B was wearing oxygen at 3 liters. The clinical record for Resident B was reviewed on 9/5/24 at 1:25 p.m. The diagnoses included, but were not limited to, acute and chronic respiratory failure, type 2 diabetes, stage 3 chronic kidney disease, obstructive sleep apnea, and retention of urine. The resident was admitted on [DATE]. While reviewing the resident's care plan, the resident did not have a baseline care plan for the use of oxygen. During an interview, on 9/6/24 at 2:31 p.m., the Chief Nursing Officer (CNO) indicated there was not a respiratory baseline care plan for the resident. The policy was for the baseline care plan to be started within 48 hours of admission.2. The clinical record for Resident 34 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-10 · 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 administer an as needed medication for weight gain, to notify the physician of a weight gain and to hold insulin doses per the physician's orders for 2 of 2 residents reviewed for quality of care. (Resident 34 and 68) Findings include: 1. The clinical record for Resident 34 was reviewed on 9/4/24 at 2:39 p.m. The diagnoses included, but were not limited to, pneumonia, acute respiratory failure with hypoxia (absence of enough oxygen to sustain bodily functions), acute on chronic systolic congestive heart failure (heart is unable to pump blood as well as it should), and chronic kidney disease stage 3. A physician's order, dated 7/28/24, indicated to weigh the resident daily and to notify the physician if the resident had a weight gain of 3 pounds in a day or 5 pounds in a week for congestive heart failure. A physician's order, dated 7/28/24, indicated to give furosemide (a diuretic medication) 40 milligrams (mg) by mouth every 24 hours as needed (PRN) for a greater than 3-pound weight gain. The vitals record in 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. During an observation, on 9/3/24 at 10:51 a.m., Resident B was wearing oxygen at 3 liters. The clinical record for Resident B was reviewed on 9/3/24 at 1:25 p.m. The diagnoses included, but were not limited to, acute and chronic respiratory failure, type 2 diabetes, stage 3 chronic kidney disease, obstructive sleep apnea, and retention of urine. The resident was admitted on [DATE]. While reviewing the resident's physician's orders, the resident did not have an order for the use of oxygen. During an interview, on 9/3/24 at 3:01 p.m., the DON indicated she was not aware the resident did not have an order for oxygen. During an interview, on 9/10/24 at 12:00 p.m., the DON indicated they did not have a policy for physician's orders. A current facility policy, titled CPAP/BiPap CLEANING POLICY, dated as last revised and received from the Director of Nursing on 9/10/24 at 11:58 a.m., indicated, .Nebulizer/BiPap/CPAP mask and oxygen tubing is to be stored in plastic bag when not in use 3.1-47(a)(6) Based on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-10 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    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 assessments were completed and a consent was obtained prior to the use of side rails for 2 of 3 residents reviewed for accident hazards. (Resident O and 63) Findings include: 1. During an observation, on 9/3/24 at 9:34 a.m., 9/3/24 at 10:49 a.m., 9/4/24 at 9:19 a.m., 9/5/24 at 2:42 p.m., 9/6/24 at 1:40 p.m., 9/9/24 at 2:54 p.m., and 9/10/24 at 10:47 a.m., a side rail was in the raised position and in use on Resident O's bed. The clinical record for Resident O was reviewed on 9/4/24 at 2:02 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, type 2 diabetes mellitus with diabetic neuropathy and hyperglycemia, unsteadiness on feet, weakness, lack of coordination, difficulty in walking, peripheral vascular disease, anxiety disorder, chronic pain syndrome, hypertension, and major depressive disorder. A side rail assessment, completed on 7/24/23, indicated Resident O did not need a side rail to assist in bed mobility. The electronic record did not have documentation…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-10 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 PRN (as needed) psychotropic medication was not ordered beyond 14 days or the attending physician documented their rationale in the resident's medical record to indicate the duration for the PRN order for 2 of 5 residents reviewed for unnecessary medications. (Resident K and 183) Findings include: 1. The clinical record for Resident K was reviewed on 9/5/24 at 10:54 a.m. The diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, fibromyalgia, type 2 diabetes mellitus with hyperglycemia, recurrent major depressive disorder with psychotic symptoms, insomnia, unspecified affective mood disorder, anxiety disorder, post-traumatic stress disorder, and unspecified psychosis not due to a substance or known physiological condition. A physician's order, dated 2/9/24, indicated to give 1 tablet of alprazolam (an anti-anxiety medication) 0.25 mg (milligrams) by mouth every 12 hours as needed for anxiety with a 90 day stop date of 5/9/24. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · Dcited before2024-09-10 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure food was being served at proper (safe and appetizing) temperature for 1 of 1 kitchen reviewed for safe food temperatures. Findings include: During an interview, on 9/3/24 at 11:22 a.m., Resident E indicated room trays were often delivered late, and the food was cold. The posted mealtimes were as followed: Breakfast: 7:00 a.m. to 8:00 a.m. Lunch: 12:00 p.m. to 1:00 p.m. Dinner: 5:00 p.m. to 6:00 p.m. During a continuous dining observation, on 9/3/24 from 12:17 p.m. to 12:57 p.m., 30 residents in the dining room were served lunch. During a continuous dining observation, on 9/3/24 from 12:57 p.m. to 1:08 p.m., room trays were delivered to residents on the 200 hall and 400 hall. During a continuous dining observation, on 9/3/24 from 1:08 p.m. to 1:20 p.m., room trays were delivered to residents on the 500 hall and 600 hall. During the delivery of the room trays on the 500 hall, at 1:17 p.m., a food temperature check was requested on the last room tray. During an observation and interview, on 9/3/24 at 1:17…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-10 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure a resident was placed in contact isolation immediately after being tested and while waiting for the results for Clostridium Difficile (C-Diff) for 1 of 1 resident reviewed for antibiotic use. (Resident B) Finding includes: During an observation, on 9/3/24 at 10:51 p.m., Resident B was on enhanced barrier precautions. The clinical record for Resident B was reviewed on 9/5/24 at 1:25 p.m. The diagnoses included, but were not limited to, acute and chronic respiratory failure, type 2 diabetes, stage 3 chronic kidney disease, obstructive sleep apnea, and retention of urine. A nursing progress note, dated 9/2/24, indicated the resident had an episode of bowel movement which was foul smelling and mucus in appearance. The physician was notified. A physician's order, dated 9/2/24 at 11:30 a.m., indicated to obtain a stool sample. A physician's order, dated 9/2/24, indicated the Medical Doctor (MD) started Resident B on Flagyl (an antibiotic) 500 mg (milligram) by mouth three times per day for diarrhea to rule…

    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 · F2023-09-01 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure the refrigerator did not contain employee drinks, the dishwasher was washing at the recommended temperature and the sanitizing solution bucket levels were in range. This deficient practice had the potential to affect 77 of 77 residents who received food from the kitchen. Findings include: During the kitchen observation, on 8/27/23 at 11:06 p.m., with the Dietary Manager (DM) the following were observed: a. The reach-in refrigerator contained a medium size fast-food cup with a brown drink and a straw. b. The red sanitizer bucket was tested twice. The DM placed a test strip into the bucket and the strip did not change colors. She tested the bucket again using a strip from a different container and the strip did not change color. c. The dishwasher was put through the wash and rinse cycle twice. The first time the rinse temperature was 117 degrees Fahrenheit and the second time the rinse temperature was 116 degrees Fahrenheit. An Installation and Operation Manual from [name of appliance company] indicated…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-01 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure the reconciliation of controlled drugs in 3 of 3 medication carts reviewed for controlled drugs and to maintain insulin medication integrity for 2 of 2 residents reviewed for insulin medication distribution. (Residents 15 and 4) Findings include: 1a. During the record review of controlled drug records, on 8/30/2023 at 3:01 p.m., the Medication Cart 200, Shift Change Controlled Substance Inventory Count Sheet (narcotic count record- reconciliation) was incomplete for the Month of August 1 through 27, 2023. The narcotic count record -reconciliation sign in and sign out documentation record for August 1 through 27, 2023 was missing 48 of 124 entries. b. During the record review of controlled drug records, on 8/30/2023 at 3:08 p.m., the Medication Cart 400, Shift Change Controlled Substance Inventory Count Sheet (narcotic count record- reconciliation) was incomplete for the Month of August 1 through 27, 2023. The narcotic count record -reconciliation sign in and sign out documentation record for August 1…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-01 · tag F0550 — failed to protect resident dignity and rights — isolated
    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

    3. During an observation, on 8/27/23 at 12:33 p.m., QMA 7 was standing next to Resident 40 feeding her. CNA 8 took over feeding the resident and she remained standing until the resident finished. During an observation, on 8/29/23 at 12:33 p.m., the Activity Director was assisting the resident to eat while she was standing next to her. She kneeled on the floor beside the resident at 12:36 p.m., then stood back up to assist her to eat. The record for Resident 40 was reviewed on 8/27/23 at 1:00 p.m. Diagnoses included, but were not limited to, dysphagia and Alzheimer's disease. A care plan, dated 8/15/23, indicated eating may fluctuate throughout the day, but usual performance was supervision or touching assistance. During an interview, on 8/30/23 at 3:30 p.m., the Activity Director, who was also a CNA, gave a copy of the items reviewed in the state approved curriculum for dining assistants (used to train feeding assistants to assist residents to eat). She indicated the staff were taught to sit next to the resident and not across from them. She was not sure why this was not listed on…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-01 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to update the care plan for a resident after acquiring a pressure ulcer on his heel for 1 of 3 residents reviewed for pressure ulcers. (Resident 73) Finding includes: The record for Resident 73 was reviewed on 8/29/23 at 10:02 a.m. Diagnoses included, but were not limited to, severe calorie malnutrition, traumatic brain injury, need for assistance with personal care, anemia, and lower back wound. A skin and wound progress note, dated 6/28/23 at 12:32 p.m., indicated Resident 73 had developed a new pressure ulcer on his right heel. A care plan, dated 6/15/23, indicated to monitor the progress of the resident's skin condition, notify the nurse of new areas of skin breakdown, provide a pressure redistribution mattress to the bed, and provide incontinence care as needed. The care plan did not include the new pressure ulcer on the right heel. During an interview, on 9/1/23 at 9:47 a.m., the Clinical Support Nurse indicated there was no care plan with revisions for the resident's new pressure ulcer for his right heel. During 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 · D2023-09-01 · 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, record review and interview, the facility failed to ensure a resident was getting her teeth brushed twice daily as ordered by the dentist for 1 of 1 resident reviewed for dental care. (Resident 40) Finding includes: During an observation, on 8/28/23 at 12:25 p.m., Resident 40 was talking and there was a very foul odor noted from the resident's mouth. The record for Resident 40 was reviewed on 8/29/23 at 11:30 a.m. Diagnoses included, but were not limited to, dysphagia (difficulty swallowing), anxiety, Alzheimer's disease, and age-related cataract. A dental note, dated 4/4/23, indicated the resident's oral hygiene was poor. A dental note, dated 7/18/23, indicated the resident had heavy generalized plaque (a sticky film coating teeth which contains bacteria), heavy calculus (hardened dental plaque) and generalized bleeding. The gingival (tissue surrounding the teeth) tissue was red and inflamed. The instructions included for the staff to please assist the resident to brush her teeth twice daily and to focus on the gumlines. A care plan, dated 8/15/23, indicated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-01 · 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

    3. During an observation, on 8/29/23 at 3:40 p.m., Resident 33 was sitting in her wheelchair, in the dining room, her legs were dangling to the floor and both lower legs were swollen. During an observation and interview, on 8/31/23 at 9:55 a.m., the resident indicated her legs were swollen and they were heavy. The resident's legs appeared to have edema. The record for Resident 33 was reviewed on 8/29/22 at 12:12 p.m. Diagnoses included, but were not limited to, congestive heart failure, chronic kidney disease, and hypertension. A care plan, dated 6/22/22, indicated the resident had an alteration in her nutritional status related to congestive heart failure. The interventions included, but were not limited to, obtain weight as indicated and report to the Registered Dietician, Physician, and family of significant weight changes. A physician's order, dated 6/14/21, indicated to call the Cardiologist if the resident had a 5 or more-pound (lb.) weight gain in one week. The resident was to be weighed on Mondays and before breakfast. A physician's order, dated 7/17/22, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-01 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    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 record review and interview, the facility failed to notify the physician, implement interventions timely and to include re-weights with a date completed in the electronic record (EHR) for significant weight changes for 2 of 5 residents reviewed for nutrition. (Resident 14 and 42) Finding includes: 1. The record for Resident 14 was reviewed on 8/30/23 at 11:49 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, iron deficiency anemia, and major depressive disorder. A physician's order, dated 10/13/22, indicated to give a regular diet with mechanical soft texture and regular liquids. A physician's order, dated 10/1/22, indicated a monthly weight and vital signs. The resident had the following weights: 1. On 7/17/23, the weight was 127.6 pounds. 2. On 8/2/23, the resident's weight was 119 pounds which was a 6.74% weight loss in less than one month. A nutrition note, dated 8/16/23 at 10:42 a.m., indicated a weight warning. The resident had a 5% change from the last weight and was a noted significant weight loss. A re-weight would be requested. The Memory Care…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-01 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure an enteral (a feeding directly into the stomach) feeding tube was unclamped and connected to the feeding 1 of 1 resident reviewed for tube feeding. (Resident 50) Finding includes: During an observation, on 8/29/23 at 9:55 a.m., Resident 50's floor had a large puddle of enteral (refers to intake of food via the gastrointestinal (GI) tract) feeding on the right side of the bed. The resident's sheet and pad were soaked with the feeding. The record for Resident 50 was reviewed on 8/29/22 at 1:05 p.m. Diagnoses included, but were not limited to, Wernicke's encephalopathy (caused by a thiamine deficiency), gastrostomy status, and anxiety disorder. A physician's order, dated 6/8/23, indicated to give Nutren 2.0 (for the nutritional management of those with limited fluid tolerance and/or increased energy needs) at 84ml (milliliters)/hr for 20 hours and a water flush of 40ml/hr for 20 hours. The formula ran from 3 p.m. to 11 a.m. At 11a.m., disconnect the feeding and restart feeding at 3 p.m. A care plan…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-01 · 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 a resident had a physician's order for the administration of oxygen (02) and failed to ensure an oxygen saturation (02 sat) was obtained prior to setting the liter per minute (LPM) flow rate of the oxygen for 1 of 1 resident reviewed for oxygen. (Resident 66) Finding includes: During an observation, on 8/27/23 at 3:26 p.m., Resident 66 was lying in bed in her room and had 02 in place per nasal cannula at 3 LPM. The resident's physician's orders did not include oxygen administration. During an interview and observation, on 8/27/23 at 3:29 p.m., QMA 3 indicated she could not find During an observation, on 8/28/23 at 11:40 a.m., Resident 66 was lying in bed in her room and had 02 per nasal cannula in place. The oxygen was set at 0 which indicated no oxygen was being administered through the nasal cannula. QMA 4 confirmed the resident's 02 was set at 0 and she would call the nurse from the other unit to set the 02. The resident had returned from the hospital early in the morning and it was scary her 02 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-01 · tag F0725 — failed to have enough nursing staff — isolated
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to have Certified Nursing Assistants (CNA) coverage for the evening shift to ensure residents on the Memory Care Unit (MCU) received showers during the evening shift for 3 of 3 residents reviewed for evening showers. (Residents 14, 40 and 15) Findings include: 1. The Facility Assessment tool indicated the facility was staffed daily by the following: a. Day shift required 9 QMAs or CNAs. b. Evening shift required 8 QMAs or CNAs c. Night shift required 5 QMAs or CNAs The Daily Nursing Schedule indicated on 8/20/23 the evening shift had a total of 7 QMAs and CNAs. The Facility Assessment called for a total of 8 QMAs and CNAs. The Daily Nursing Schedule indicated on 8/30/23 the evening shift had a total of 5 QMAs and CNAs with 1 CNA in orientation. The Facility Assessment called for a total of 8 QMAs and CNAs. During an interview, on 9/1/23 at 3:30 p.m., the Scheduler indicated the Eastside of the facility had 3 CNAs during day and the QMA worked 12 hours a day. The Westside was staffed with a QMA from 6 a.m.-6 p.m., and two CNAs…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-01 · tag F0727 — failed to provide required RN coverage — isolated
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    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 there was RN coverage for multiple days for the 2nd Quarter of 2023 from 1/1/2023 to 03/31/2023. Finding includes: The Staffing information was reviewed on 8/31/23 at 1:40 p.m. The Payroll Based Journal (PBJ) report for the 2nd Quarter during 2023, indicated the following area was triggered. a. No RN coverage for 8 consecutive hour/day and triggered for the dates of 1/1, 1/2, 1/8, 1/9, 1/14, 1/21, 1/22, 1/23, 2/4, 2/5, 2/7, 2/11, 2/18, 3/19, 3/22, 3/23, 3/24, 3/25, 3/27, 3/28, 3/31/23. The Facility Assessment tool indicated the facility was staffed daily by the following: a. Day shift required 2 RNs. b. Evening shift required 2 RNs. c. Night shift required 1 RN. During an interview, on 9/1/23 at 3:30 p.m., the Executive Director (ED) indicated she was given the Certification and Survey Provider Enhanced Reports 3 (CASPER 3) at the entrance conference. The areas triggered in the Payroll Based Journal (PBJ) was the facility was one-star, low weekend staff and no RN coverage for 8 consecutive hour/day for the dates 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-01 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to provide a consistent program of cognitively stimulating activities for a resident with dementia for 1 of 4 residents reviewed for dementia care. (Resident 52) Finding includes: During an observation, on 8/27/23 at 3:45 p.m., Resident 52 was lying in bed in her room and was wearing a hospital gown. Several other residents were sitting in the common area with the staff, and they were getting ready to play bingo. During an observation, on 8/28/23 at 12:29 p.m., the resident was lying in bed in her room. Several other residents were in the common area and eating lunch together. During an observation, on 8/29/23 at 11:28 a.m., the resident was lying in bed in her room, her eyes were closed, and she was wearing a hospital gown. Several other residents were in the common area playing balloon toss and listening to music with the activity staff. During an observation, on 8/29/23 at 4:06 p.m., the resident was lying in bed in her room. Several other residents were playing bingo with the activity staff. During 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-01 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to prepare pureed foods according to the recipes in the kitchen for 5 of 5 residents who were ordered a pureed diet. Finding includes: During the observation of pureed foods, on 8/27/23 at 11:38 a.m., the Dietary Manager (DM) was observed to do the following: a. The DM put 3/4 cup of juice into the Robo coupe (a machine to puree foods). She placed 10 peaches into the Robo coupe. Then the DM placed 2/3 cup of thickener into the machine. b. The DM put an unmeasured amount of California blend vegetables into the Robo coupe with an unmeasured amount of margarine and added 2/3 cup of thickener. c. The DM poured a 1/2 cup of chicken broth into the Robo coupe, added 2 scoops of alfredo, and then added 2/3 cup of thickener. d. The DM added 4 bread sticks into the Robo coupe and poured in 1 and 1/2 cups of milk and added 2/3 cup of thickener. The recipe the DM used for the Pureed Peach Cobbler indicated for 5 servings of peaches cobbler to blend 5 servings of prepared peach cobbler and 1/2 cup of juice and blend until…

    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
  • No harm found · C2025-08-15 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the daily nurse staffing data was posted at the beginning of each shift on 1 of 6 survey observation dates. (8/10/25)Findings include:During an observation, on 8/10/25 at 12:21 p.m., the posted nurse staffing data sheet was dated for 8/8/25.During an interview, on 8/11/25 at 12:55 p.m., the Director of Nursing (DON) indicated the scheduler created the daily nurse staffing data forms and posted it each morning. On the weekends, she created it ahead of time, and the manager on duty was supposed to post it each morning. The Saturday and Sunday sheets were placed in the posting frame behind Friday's sheet to be pulled forward over the weekend. If there were call-ins or changes, it would not reflect those on the weekend or night shifts after she went home. The staffing should be posted each morning, even during the weekend. If the posted sheet was dated 8/8/25, then the nurse staffing data sheet for 8/9/25 must not have been pulled forward on Saturday and Sunday's sheet was not pulled forward at the beginning of 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to CASTLE HEALTHCARE — 7 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 5 of 53.0+2.0 vs chain
Health inspection 4 of 52.6+1.4 vs chain
Staffing 2 of 51.6+0.4 vs chain
Quality measures 5 of 54.7+0.3 vs chain
The other 6 homes this chain runs (chain average 3.0★, 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 / managerTypeRoleShareSince
HENRY COUNTY MEMORIAL HOSPITALOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 06/03/2025
FRANKFORT REALTY LLCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 11/01/2020
DYNES, SHELDONIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 01/01/2013
PIDGEON, JOHNIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 01/01/2013
RING, BRIANIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 08/01/2022
SHORE, MARIONIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2013
WARE, DEBORAHIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 08/27/2021
CLAYSHIRE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023
FRANKFORT REHABILITATION AND HEALTHCARE CENTER, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2020
LT CARE ACQUISITION CORPOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2020
BERDUGO, SHAIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023
SHAFER, MATTHEWIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/17/2025
WASHINGTON, LANCEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2022
FRIEDMAN, YISRAELIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 06/04/2025
SINGER, MEIRIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 06/03/2025
CASTLE INDIANA MANAGEMENT LLCOrganizationADP OF THE SNFsince 01/01/2023
WEINTRAUB, MOSHEIndividualADP OF THE SNFsince 11/01/2020

CMS files one row per role, so the 29 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted.

6 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.

$10.1M
Net patient revenuemost recent cost report
+9.8%
Operating marginrevenue minus expenses
$1.7M
Related-party expense19% of expenses
Who pays — share of resident-days
Medicaid 75%Medicare 5%Other / private 20%

About 75% 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 $1.7M paid to related parties — landlords or management companies under common ownership — equal to about 19% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$321per resident / day
operating cost
$9,754per month
≈ monthly operating cost
$356per 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 155295. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-15, 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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