Belltower Health & Rehabilitation Center
5805 North Fir Road, Granger, IN 46530 · For profit - Corporation · 96 certified beds · (574) 406-6600 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- 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
- lower-than-typical staff turnover (30% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 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.
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 | 16.2% | 11.0% | 15.4% | typical |
| Long-stay residents who lose too much weight | 7.7% | 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 | 0.3% | 1.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 11.8% | 25.2% | 6.5% | better 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 | 5.7% | 3.9% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 19.3% | 11.9% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 12.8% | 23.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.7% | 3.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 27.1% | 23.3% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.9% | 13.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 98.8% | 79.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.6% | 22.2% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 14.7% | 10.8% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.02 | 1.61 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.42 | 1.44 | 1.80 | worse |
‡ 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.
56.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 123 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 74.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 47 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.21 therapist hours per resident per day in 2026Q1 — more than 26% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% 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 | 56.6%CMS range 46.8–64.6 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.7%CMS range 7.2–15.1 | 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 | 74.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 68.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 72.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 96.2% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF 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 4.7–12.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.09 | 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 96 beds and averages 89.4 residents a day — about 93% occupied, or roughly 7 beds typically open. It runs fairly full. 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 3.35 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.03 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.06 hrs/resident/day on weekends vs 3.46 on weekdays — 12% thinner on weekends. RN hours go from 0.52 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 30% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
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.
22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.
- Potential for harm · Dcited before2025-10-29 · 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 physician orders were carried out timely for 1 of 3 residents reviewed for urinary tract infection. (Resident B). Finding includes:On 10/27/25, Resident B's medical record was reviewed. Diagnoses included but were not limited to dementia, type 2 diabetes, morbid obesity, chronic obstructive pulmonary disease, rheumatoid arthritis, urinary tract infection, hypertension, history of breast cancer, depression, and chronic kidney disease.Resident B's most recent comprehensive Minimum Data Set (MDS) assessment was a Quarterly assessment dated [DATE]. The Assessment indicated Resident B was able to communicate with others, made herself understood and understood others, had moderate cognitive impairment, and demonstrated no negative behaviors. The resident required substantial assistance for personal hygiene, toileting hygiene, bathing, and partial assistance for transferring, was frequently incontinent of bladder and bowel and was at risk for pressure…
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 · Fcited before2025-06-09 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 store food in a sanitary manner related to undated and unlabeled foods and drinks for 1 of 1 kitchen areas observed. (Main kitchen) This issue had the potential to affect 82 of 83 residents who consumed food from the kitchen. Finding includes: During an initial tour of the kitchen, on 6/2/2025 at 9:50 A.M. with the Dietary Manager (DM), the following foods were observed in the walk-in cooler undated, unlabeled or expired: -a container of blue liquid, undated and unlabeled. -2 unopened packages of bologna with a use or freeze by date of 5/1/2025. -half a turkey breast, wrapped in saran wrap, undated and unlabeled. On 6/2/2025 at 10:30 A.M., the following foods were observed in the walk-in freezer undated or unlabeled: -2 Ziploc bags containing a pastry-rolled food item, undated and unlabeled. -1 bag of artichoke dip, unlabeled and undated. -multiple pieces of fish wrapped in saran wrap, unlabeled and undated. -a white piece of meat wrapped in saran wrap, unlabeled and undated. -a steak wrapped in saran wrap,…
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 · D2025-05-08 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure an allegation of abuse resolution was followed regarding care assignments for 1 of 3 residents reviewed for abuse. (Resident C) Finding includes: A record review for Resident C was completed on 5/8/2025 at 8:45 A.M. Diagnoses included, but were not limited to: dementia, psychosis, anxiety disorder and narcolepsy. A Quarterly Minimum Data Set (MDS) assessment, dated 2/20/2025, indicated Resident C had moderate cognitive impairment and required substantial/maximal assistance of one staff member for showers and transfers. A facility reported incident investigation was completed and sent to the Indiana Department of Health on 4/16/2025. The report indicated an insurance case manager had interviewed Resident C and he had reported he felt unsafe and did not like CNA 2 (certified nursing assistant) who cared for him. As a result of the investigation, Resident C was informed CNA 2 would no longer be assigned to care for him. Resident C was satisfied with the resolution. Point of Care documentation (electronic CNA…
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 before2025-05-08 · 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 record review and interview, the facility failed to follow a physician's order when administering blood pressure medication for 1 of 6 residents reviewed for quality of care. (Resident E) Finding includes: A record review for Resident E was completed on 5/7/2025 at 11:28 A.M. Diagnoses included, but were not limited to: vascular dementia, cerebral infarction (stroke) hypertension and atrial fibrillation. An admission Minimum Data Set (MDS) assessment, dated 2/7/2025, indicated Resident E had severe cognitive impairment. A Nurse Practitioner Note, dated 4/4/2025, indicated Resident E's hypertension was chronic, stable and staff were to monitor Resident E's blood pressure closely. A Care Plan, initiated on 2/3/2025 and updated on 5/7/2025, indicated Resident E had hypertension and received antihypertensive medication. The goal was to promote vascular perfusion with the blood pressure to be within normal range. The interventions included, but were not limited to: to administer medications as ordered, monitor the medications effectiveness, watch for severe reactions and to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-07-29 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 store and prepare food in a sanitary manner related to expired leftovers, open and undated food in the walk-in cooler and skillets with missing Teflon for 1 of 1 kitchens reviewed. This had the potential to affect 69 of 69 residents who received their meals from the kitchen. Findings include: During the initial kitchen tour on 7/22/2024 at 9:00 A.M with the Certified Dietary Manager (CDM), the following was observed in the walk-in cooler: -A plastic container with pasta noodles dated, 7/11/2024. -An opened jar of jalapenos with no opened on or use by dates. -An opened jar of enchilada sauce with no opened on or use by dates. -An opened bag of whipped topping with no opened on or use by dates. -3 cups of mixed berries with no made on or use by dates. -3 cups of yogurt with no made on or use by dates. During the initial kitchen tour with the CDM on 7/22/2024 at 9:20 A.M., three skillets utilized by the facility for preparing meals were found to be scratched and missing some of the Teflon coating. 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.
- Potential for harm · Dcited before2024-07-29 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to develop a care plan regarding communication needs for 1 of 1 residents reviewed for Communication and Sensory Needs (Resident 39) and accident hazards for 1 of 1 residents reviewed for Accidents. (Resident 56) Findings include: 1. A record review for Resident 39 was completed on 7/24/2024 at 9:53 A.M. Diagnoses included, but were not limited to, cerebral infarction, neoplasm of the lower jaw bone, and occlusion and stenosis of the right carotid artery. A Quarterly Minimum Data Set (MDS) assessment, dated 7/5/2024, indicated Resident 39 was moderately cognitively impaired, his vision and hearing were adequate, his speech was sometimes understood and he sometimes understood others and he required substantial to maximal assistance from staff for bed mobility needs. The Progress Notes, since he was admitted , indicated Resident 39 was unable to use the call light and staff anticipated his needs. The care plan lacked a problem, goal, or interventions related to the resident's inability to use the call light or the provision 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 · D2024-07-29 · 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, observation and record review, the facility failed to keep ensure Resident 56's environment was free of potential hazards for 1 of 1 resident reviewed for environmental hazards. (Resident 56) Finding includes: During an interview on 7/22/2024 at 10:04 A.M., Resident 56 indicated she cooked all of her own meals and does not eat the facility's food. Her brother takes her to the store to buy food once a week. An observation was completed on 7/22/2024 at 10:10 A.M. Resident 56 had an air fryer on a table, plugged in to the electric outlet. There was a spatula hanging on the wall above the air fryer. Resident 56's record review was completed on 7/22/2024 at 10:50 A.M. Her diagnoses included, but were not limited to: type 2 diabetes mellitus and hypertension. A Quarterly Minimum Data Set Assessment (MDS) dated , 6/25/2024, indicated the resident had moderate cognitive impairment. Resident 56's record lacked the documentation she had a Care Plan to address her ability to cook in her room or a Care Plan indicating she had refused to follow the facility's policy regarding…
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 · E2023-08-14 · tag F0657 — failed to keep the care plan current — patternDevelop 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 observation, record review and interviews, the facility failed to ensure a care plan meeting was conducted timely and care plans revised timely for 4 of 19 residents reviewed for careplanning. (Resident 15, 39, 58 and179) Finding includes: 1. The record for Resident 15 was reviewed on 8/14/2023 at 12:30 P.M. Resident 15 was admitted to the facility with diagnoses included, but not limited to: nontraumatic subarachnoid hemorrhage, atherlosclerotic heart disease, chronic atrial fibrillation, hyperlipidemia, type 2 diabetes mellitus, mild cognitive impairment of uncertain or unknown etiology, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and insominia. The Quarterly, MDS (minimum data set) assessment, completed on 6/20/2023, indicated Resident 15 was alert and oriented, required extensive assist of two staff for bed mobility, dressing and extensive assist of one for personal hygiene and toileting needs and was totally dependent for bathing needs, had not transferred out of bed, had two stage 3 unhealed pressure ulcers, and 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.
- Potential for harm · Ecited before2023-08-14 · 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
Based on observation, interview, and record review, the facility failed to ensure food was stored in accordance with professional standards for food safety. This deficient practice had the potential to affect the 80 of 82 residents who received food from the kitchen. Findings include: 1.During a tour of the kitchen, conducted on 8/7/2023 at 7:29 A.M. to 7:44 A.M., with the Dietary Manager, the following was observed: - In the dry storage there was an open bag of heath toffee candy pieces and bag of nachos undated. -The freezer had a bag of hash browns and jalapeno poppers not sealed. - The reach in refrigerator had 2 open gallons all items without an open date. During an interview, on 8/7/2023 at 7:43 A.M., the Dietary Manager indicated that all items should have an open date and the 2 items in the freezer should have been sealed properly. 2. During a tour of the nourishment rooms on 8/14/2023 between 10:04 A.M. to 10:13 A.M., with the Dietary Manager, the following was observed: -The long term care room had a container with vegetables/salad in a plastic shopping bag without a name…
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 · D2023-08-14 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Physician Orders for Scope of Treatment (POST) form matched the Physician order for 1 of 82 residents whose Advanced Directives were reviewed (Resident 232). Finding includes: A record review was completed on [DATE] at 1:16 P.M. Resident 232's POST form was signed by the resident on [DATE] indicating to attempt CPR (Cardiopulmonary Resuscitation), and full interventions to meet medical needs. The POST form was signed by the physician on [DATE]. A Physician order, dated [DATE], indicated Resident 232's code status was a DNR (Do Not Resuscitate). A Care Plan, with a start date of [DATE], indicated that Resident 232 had elected a full code status with a goal of directing medical care to make values and treatments known in which stated desires would be honored. Approaches to support Resident 232's code status included, but were not limited to, notifying the physician of resident's desires and any needed physician's order obtained. 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.
Show the remaining 12 citations
- Potential for harm · D2023-08-14 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
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 that transfer and discharge paperwork was completed and given to a resident or family members and failed to notify the ombudsman in a timely manner of resident's discharge from the facility for 1 of 1 residents reviewed for notification of discharge. (Resident 76) Finding Includes: A record review was conducted on 8/14/23 at 2:49 P.M., for Resident 76. Diagnoses included, but were not limited to: urinary tract infection, acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity, malignant neoplasm of uterus, inflammatory disease of uterus. An admission MDS (Minimum Data Set) assessment, date 5/8/2023, indicated the resident was cognitively intact. A Discharge MDS assessment, dated 7/11/2023, indicated the resident had been discharged with an anticipated return to facility. A Progress Note, dated 7/11/2023 at 4:15 A.M., indicated Resident 76 had a significant change in condition and was sent to the ER (Emergency Room). No documentation was available that indicated transfer forms 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 · D2023-08-14 · tag F0636 — isolatedAssess 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 observation, record review and interviews, the facility failed to ensure the comprehensive assessment was accurate and completed for 2 residents reviewed for dental status and bowel and bladder continence . (Resident 1 &51) Findings include: 1. The record for Resident 1, reviewed on 8/10/2023 at 2:54 P.M., indicated the resident was admitted to the facility with diagnosis, including but not limited to: multiple sclerosis, dry mouth and limitation of activities due to disability. The most recent Quarterly Minimum Data Set (MDS) assessment, completed on 6/29/2023, indicated the resident was alert and oriented and there was no indication, under the Oral/Dental Status section of the resident being edentulous (without teeth). Resident 1 was identified as requiring extensive to total staff assistance for activities of daily living, including personal hygiene, transfers and wheelchair locomotion. The significant change MDS assessment, completed 11/2/2022, did not assess the resident as being edentulous. During an interview with Resident 1, on 8/8/2023 at 9:01 A.M., she indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-14 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interviews, the facility failed to ensure care plans were developed for 2 of 19 residents reviewed for care planning. (Residents 1 for dental care and Resident 15 Diabetes, Diuretic, anithypertensive and Vitamin D medication use) Findings include: 1. The record for Resident 1, reviewed on 8/10/2023 at 2:54 P.M., indicated the resident was admitted to the facility with diagnoses, included but not limited to: multiple sclerosis, dry mouth and limitation of activities due to disability. The Quarterly Minimum Data Set (MDS) assessment, completed on 6/29/2023, indicated the resident was alert and oriented and there was no indication, under the Oral/Dental Status section of the resident being edentulous (without teeth). The Significant Change MDS assessment, completed 11/2/2022, did not assess the resident as being edentulous. The current health care plans for Resident 1 included a plan to assist the resident with activities of daily living but the plan was not specific to what kinds of oral/dental assistance the resident needed. During an interview…
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 · D2023-08-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 interviews, the facility failed to ensure nail care was provided for 1 of 6 residents reviewed for Activities of Daily Living (ADL) needs. (Resident 20) Finding includes: A record review was completed for Resident 20 on 8/8/2023 at 3:09 P.M. Diagnoses included, but were not limited to: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia and dementia without behavioral disturbances. A Quarterly Minimum Data Set assessment, dated 5/15/2023, indicated she was totally dependent for bathing and extensive assist of one with grooming and personal hygiene. A Care Plan, dated 11/15/2023, indicated Resident 20 required assistance with activities of daily living (ADL's) due to cerebral vascular accident with right side hemiplegia. Interventions included: bathing dependent of one staff and dressing extensive assist of one. During an observation, on 8/7/2023 at 11:58 A.M., Resident 20's last 3 fingers on her right-hand curled under, her nails were long and jagged with a brown substance under them and her toe…
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 before2023-08-14 · 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, record review and interviews, the facility failed to ensure 1 of 1 residents reviewed for Hospice services, received coordinated care between Hospice and the facility. (Resident 15) Finding includes: Resident 15 was admitted to the facility with diagnoses included, but not limited to: nontraumatic subarachnoid hemorrhage, arteriosclerotic heart disease, chronic atrial fibrillation, hyperlipidemia, type 2 diabetes mellitus, mild cognitive impairment of uncertain or unknown etiology, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, HTN, morbid obesity, neuromuscular dysfunction of the bladder, dysphasia, post COVID 19, depression, constipation, insomnia. On 1/24/2023, major depressive disorder, recurrent, mild was added to his diagnosis list. The Quarterly MDS (minimum data set) assessment, completed on 6/20/2023, indicated Resident 15 was alert and oriented, required extensive assist of two staff for bed mobility, dressing and extensive assist of one for personal hygiene and toileting needs and was totally dependent for…
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 · D2023-08-14 · 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 record review, observation and interview, the facility failed to ensure a resident had interventions in place to prevent the development of a DTI (deep tissue injury) skin area for 1 of 4 residents reviewed for pressure ulcers. (Resident 39) Finding includes: During an interview, on 8/11/2023 at 11:55 A.M., the Assistant Director of Nurses (ADON) indicated Resident 39 had a non- pressure area to the right buttocks, and a deep tissue injury to the left heel. During an observation, on 8/11/2023 at 11:57 A.M., the following was observed on the left heel: a dark purple area approximately 1 x 1/2. The ADON indicated at times the aides would put a pillow under the legs. The ADON indicated the area was measured on Wednesday 8/9/2023, and measured 2.2 cm (centimeter) x 2.5 cm. During an interview, on 8/11/2023 at 11:58 A.M., Resident 39 indicated when I asked them (aides) to put the pillow under my legs they have an attitude and feel like they don't have time. The resident indicated she did not have the area before she fell and fractured her hip. A record review was completed 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.
- Potential for harm · D2023-08-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate care of a nephrostomy tube and foley catheter and Physician Orders for treatment for 1 of 1 residents reviewed for urinary and nephrostomy catheter. (Resident 179) Finding includes: A record review for Resident 179 was conducted on 8/10/2023 at 9:30 A.M. Diagnoses included, but not limited to: unspecified focal traumatic brain injury with loss of consciousness of unspecified duration, quadriplegia, persistent vegetative state, dysphagia following nontraumatic intracranial hemorrhage, gastrostomy status, and contracture of muscle sites-Bilattwrist (bilateral wrist), hip, knee, ankle. A Care Plan, dated 7/30/2023, indicated (Resident' first name) requires an indwelling urinary catheter and nephrostomy tube r/t obstructive uropathy. The goal was the following: Resident will have catheter care managed appropriately, as evidenced by: not exhibiting signs of urinary tract infection or urethral trauma. 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 · D2023-08-14 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 respiratory equipment was stored and maintained per professional standards and signage was on the door for 2 of 2 residents reviewed for respiratory care. (Resident 68) Finding includes: A record review was completed for Resident 68 on 8/11/2023 at 9:42 A.M. Diagnoses included. but were not limited to: chronic obstructive pulmonary disease and emphysema. During an observation, on 8/7/2023 at 11:34 A.M., Resident 68 respiratory storage bag was dated 7/28/2023 and oxygen humidifier was very low on water with the same date. During an observation, on 8/8/2023 at 9:35 A.M. the respiratory equipment was still dated 7/28/2023. During an observation, on 8/9/2023 at 9:14 A.M., the respiratory equipment was still dated 7/28/2023. During and observation, on 8/11/2023 at 9:11 A.M. CNA 4 entered the resident's room with a portable oxygen tank, placed the tubing on the machine then wrapped the nasal cannula around the two handles of the wheelchair. During an interview, on 8/11/2023 at 9:19 A.M., CNA 4 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 · D2023-08-14 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to initiate physician signed pharmacy recommendations to decrease a pain medication in a timely manner for 1 of 5 residents reviewed for unnecessary medications. (Resident 39) Finding includes: A record review was completed on 8/11/2023 at 2:29 P.M. Resident 39's diagnoses included, but were not limited to: hypertension, fractured hip, anxiety, depression, chronic pain, fibromyalgia and rheumatoid arthritis. A 5-day MDS (Minimum Data Set) assessment, dated 7/19/2023, indicated Resident 39 required extensive assist of 1 staff for bed mobility, transfers, dressing, toilet use and limited assist for eating. A Pharmacy Consultation Report, dated 1/5/2023, indicated Resident 39 received three or more CNS (central nervous system) medications which can cause an increase risk for fall and fractures. The recommendation was to reevaluate this combination and reduce the dose of Pregabalin (nerve pain medication) to 200 mg (milligrams) BID (twice a day) with the end goal of discontinuation. A Pharmacy Consultation Report, dated 3/6/2023,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-14 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interviews, the facility failed to ensure the medication regimen was free from unnecessary medication for 2 of 5 residents reviewed for medication use. (Resident 15 regarding monitoring of medications and 51 regarding antibiotic use) Findings include: 1. The record for Resident 15 was reviewed on 8/9/2023 at 9:52 A.M Resident 15 was admitted to the facility with diagnoses included, but not limited to: nontraumatic subarachnoid hemorrhage, atherlosclerotic heart disease, chronic atrial fibrillation, type 2 diabetes mellitus, , hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hypertension, morbid obesity, neuromuscular dysfunction of the bladder, dysphasia. The Quarterly MDS (Minimum Data Set) assessment, completed on 6/20/2023 indicated Resident 15 was alert and oriented, required extensive assist of two staff for bed mobility, dressing and extensive assist of one for personal hygiene and toileting needs and was totally dependent for bathing needs, had not transferred out of bed, had two stage 3…
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 · D2023-08-14 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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 record review and interview, the facility failed to ensure a Pharmacy Recommendation and Physician's Order, to gradually reduce an antipsychotic medication, was implemented timely for 1 of 5 residents reviewed for medication use. (Resident 15) Finding includes: The record for Resident 15 was reviewed on 8/9/2023 at 9:52 A.M. Resident 15 was admitted to the facility with diagnoses included, but not limited to: nontraumatic subarachnoid hemorrhage, mild cognitive impairment of uncertain or unknown etiology, depression and insomnia. On 1/24/2023 , a diagnoses of major depressive disorder, recurrent, mild was added. The Quarterly MDS (minimum data set) assessment, completed on 6/20/2023 indicated Resident 15 was alert and oriented, required extensive assist of two staff for bed mobility, dressing and extensive assist of one for personal hygiene and toileting needs and was totally dependent for bathing needs, had not transferred out of bed, had two stage 3 unhealed pressure ulcers, and an indwelling urinary catheter. The current medication regimen for Resident 15 included 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 · D2023-08-14 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medications were dated when opened, failed to store wound cleanser away from medications, failed to ensure medication carts were free of loose pills and failed to ensure residents alcohol bottles were labeled with resident identifiers in 3 of 3 medication carts and 1 of 1 medication rooms observed. ( F/D Medication cart, B Medication cart, Memory Care Medication cart and the Long Term Medication room) Findings include: 1. On 8/11/2023 at 9:13 A.M., a medication storage observation was completed with QMA 5 on the F/D Hall cart, the following was observed: An opened and undated bottle of Robitussin cough syrup. Three (3) opened and undated bottles of [NAME]-lax (stool softener). An opened and undated bottle of ant-acid tablets. During an interview, on 8/11/2023 at 9:15 A.M., QMA 5 indicated the medications should have had a date opened. 2. On 8/11/2023 at 9:24 A.M., a medication storage observation was completed with LPN 2 on the B…
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 FUNDAMENTAL HEALTHCARE — 66 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 | 4 of 5 | 2.4 | +1.6 vs chain |
| Health inspection | 4 of 5 | 2.5 | +1.5 vs chain |
| Staffing | 3 of 5 | 2.2 | +0.8 vs chain |
| Quality measures | 4 of 5 | 3.4 | +0.6 vs chain |
The other 65 homes this chain runs (chain average 2.4★, per CMS)
Showing 40 of 65; lowest-rated first.
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 | Since |
|---|---|---|---|
| BEATY, JEFF | Individual | CORPORATE DIRECTOR | since 02/01/2003 |
| BLACK, STEPHEN | Individual | CORPORATE DIRECTOR | since 01/01/2013 |
| BURTON, KAREN | Individual | CORPORATE DIRECTOR | since 01/01/2013 |
| CALDWELL, DANA | Individual | CORPORATE DIRECTOR | since 02/01/2008 |
| COFFIN, JOHN | Individual | CORPORATE DIRECTOR | since 10/01/2009 |
| HAEHL, PHILLIP | Individual | CORPORATE DIRECTOR | since 01/01/2013 |
| MERCURI, RALPH | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 09/01/2008 |
| SANDMAN, JAN | Individual | CORPORATE DIRECTOR | since 02/01/2006 |
| STEVENS, MELANIE | Individual | CORPORATE DIRECTOR | since 02/01/2006 |
| TANDY, SHERRI | Individual | CORPORATE DIRECTOR | since 02/01/2006 |
| CLAXTON, RYAN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/27/2025 |
| GUSTAFSON, PAULA | Individual | CORPORATE OFFICER | since 01/01/2013 |
| KUHN, HEATHER | Individual | CORPORATE OFFICER | since 01/01/2013 |
| SHIPPENSBURG HEALTH CARE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 05/20/2016 |
| CARMEAN, MARTI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/06/2019 |
| VAN DEN DRIESSCHE, THOMAS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2021 |
| FUNDAMENTAL ADMINISTRATIVE SERVICES LLC | Organization | ADP OF THE SNF | since 07/05/2016 |
| FUNDAMENTAL CLINICAL AND OPERATIONAL SERVICES, LLC | Organization | ADP OF THE SNF | since 07/05/2016 |
| MORGAN POWERS, DEANNA | Individual | ADP OF THE SNF | since 02/01/2021 |
CMS files one row per role, so the 24 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
3 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.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 155850. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-09, 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.