Waters Of Greencastle, The
1601 Hospital Dr, Greencastle, IN 46135 · Government - Hospital district · 100 certified beds · (765) 653-2602 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0565)
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (2/5)
- about 18% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 4 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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 | 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 held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 2.2% | 11.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.6% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.7% | 0.4% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 1.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 50.0% | 25.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.3% | 3.9% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 7.5% | 11.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 14.3% | 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 | 7.5% | 3.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 24.2% | 23.3% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 34.3% | 13.6% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.9% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 97.3% | 79.0% | 79.4% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.15 | 1.61 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.77 | 1.44 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.12 therapist hours per resident per day in 2026Q1 — more than 9% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 17% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.7%CMS range 7.5–17.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 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 next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not 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 SNFs | 1.07 | 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 100 beds and averages 71.1 residents a day — about 71% occupied, or roughly 29 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 3.39 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.46 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.97 hrs/resident/day on weekends vs 3.56 on weekdays — 17% thinner on weekends. RN hours go from 0.33 to 0.30 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%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.
- Immediate jeopardy · J2026-06-18 · 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 observation, record review, and interview, the facility failed to supervise and ensure the safety of a resident with dementia residing on the locked dementia unit when an exit glass door and an outside courtyard gate were left open by a contractor and the resident eloped from the facility and fell into a ditch for 1 of 3 residents reviewed for accidents (Resident B). The immediate jeopardy began on 6/2/26 at 1:58 p.m., when Resident B was observed via video footage exiting the gate from the locked unit courtyard. She continued across the parking lot into a grassy field. She walked at a rapid pace, carrying a blanket in front of her. She walked approximately 100 yards and veered towards the road and was observed falling on her face in a ditch. She was observed trying to get up and falling again. She was on the ground for 13 minutes before a hospital staff member approached her, but she was unable to stand. He indicated she was about 2 1/2 to 3 feet from the road between the facility and the hospital. Facility staff were seen arriving to assist the resident after the hospital…
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 · F2026-06-18 · tag F0835 — failed to run the facility competently — widespreadAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility Administrator and Director of Nursing (DON) failed to communicate accurate information, complete accurate documentation, and pressured facility staff to provide false statements for an elopement from the memory care unit for 1 of 5 residents reviewed for accidents (Resident B). This deficiency had the potential to affect 68 of 68 residents residing at the facility who were overseen by the Administrator and DON.Findings include:During an interview on 6/15/26 at 12:29 p.m., Resident B's spouse indicated he had been caring for his wife at home and was very sad he had to make the decision to place her in a safer environment due to her dementia. His wife was admitted to the facility on [DATE]. He received a call from the Administrator around 3:00 p.m. on 6/2/26. She indicated Resident B had a little incident when she followed a contractor out of the memory care doors and had fallen in a grassy area. She indicated she was okay. Before going into a 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.
- Potential for harm · Fcited before2025-12-05 · 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 ensure beard restraints were worn appropriately and hand hygiene was performed after staff touched their face during 5 of 5 kitchen observations. This deficient practice had the potential to affect 68 of 68 residents who ate meals from the kitchen. Findings include: 1. During a kitchen observation, on 12/1/25 at 10:05 a.m., [NAME] 7 was observed in the food preparation area, stirring a pot on the stove and preparing other food. At the same time, [NAME] 7 was observed with a full beard and mustache. [NAME] 7 had a beard restraint in place, but it only covered a small area of the beard on his chin, leaving the mustache and sides of the face open. [NAME] 7 was wearing gloves but touched his face and nose several times with his forearm and wrist area of the glove. [NAME] 7 did not wash his hands after touching his face and nose and continued to prepare food. 2. During a lunch service observation, on 12/1/25 at 12:03 p.m., [NAME] 7 was observed serving food from the steam table in the main dining room. The beard…
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 · E2025-12-05 · tag F0552 — patternEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to obtain consent for treatment of psychotropic medications for 4 of 5 residents reviewed for unnecessary medications. (Residents 7, 8, 27, and 22). Findings include:1. On 12/3/25 at 10:25 a.m., the medical record of Resident 7 was reviewed. The resident was admitted to the facility on [DATE]. admission diagnoses included, but were not limited to, dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), hypertension (high blood pressure) and depression (an illness characterized by persistent sadness and a loss of interest in activities that you normally enjoy, accompanied by an inability to carry out daily activities, for at least two weeks). The record did not indicate the resident had any related heart conditions. An admission Minimum Data Set (MDS) assessment, dated 4/2/25, indicated the resident was cognitively impaired and required extensive…
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 · E2025-12-05 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
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 grievances expressed by the residents were addressed and resolutions were explained to the residents for 6 of 24 residents reviewed for food concerns (Residents 6, 71, 38, 24, 68, and 65). Findings include:During an interview, on 12/01/25 at 11:19 a.m., Resident 6 indicated she ate in her room. The food was often cold when she got it. The residents were not getting the food that was posted on the menus. The menu had not been right for a while. She was not sure who was ordering the food, but they frequently ran out of items. They recently had run out of coffee. During an interview, on 12/02/25 at 10:52 a.m., Resident 71 indicated he did not like the food and when he asked for an alternative, he was told they did not have any. There were times when all he wanted was peanut butter and jelly and the kitchen staff told him they did not have any peanut butter. During an interview, on 12/02/25 at 11:20 a.m., Resident 38 indicated he had to buy himself his own peanut butter, jelly, and bread so that he would have…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-05 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Abnormal Involuntary Movement Scale (AIMS) (a clinical tool to detect and monitor tardive dyskinesia (TD) in patients taking (antipsychotic) medications, rating involuntary facial, limb, and trunk movements) assessments were completed timely for 2 of 5 residents reviewed for unnecessary medications (Residents 7 and 22).Findings include:1. On 12/3/25 at 10:25 a.m., the medical record of Resident 7 was reviewed. The resident was admitted to the facility on [DATE]. admission diagnoses included, but were not limited to, dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), hypertension (high blood pressure), and depression (an illness characterized by persistent sadness and a loss of interest in activities that you normally enjoy, accompanied by an inability to carry out daily activities, for at least two weeks). The record did not indicate…
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 · D2025-12-05 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessment for 2 of 17 reviewed (Residents 22 and 65).Findings include: 1. Resident 22's record was reviewed on 12/3/25 at 1:36 p.m. The profile indicated the resident's diagnoses included, but were not limited to, active primary progressive multiple sclerosis (MS - where disability worsens steadily over time, unlike the relapsing-remitting form, with symptoms like walking difficulty, fatigue, and cognitive issues), chronic obstructive pulmonary disease (COPD - a progressive lung disease, including emphysema and chronic bronchitis, that blocks airways, making breathing difficult due to inflammation, mucus, and damaged air sacs), and bipolar disorder (a lifelong mental health condition causing extreme mood swings, from manic highs to depressive lows). Facility census information indicated Resident 22 admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment, dated 9/23/25, 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 before2025-12-05 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a care plan was developed related to weight loss (Resident 7), failed to ensure a care plan was developed related skin concerns (Resident 71), and failed to ensure documentation of care plan meeting being held (Resident 19) for 3 of 24 residents reviewed for care plans. Findings include: 1. On 12/1/25 at 11:58 a.m., during initial observation observed Resident 7 in the main dining room being assisted with meal. The Certified Nurse Aide (CNA) started to assist the resident with the meal. CNA left to assist other residents. Resident continued to pick at food. Did not seem to know what to do with utensils. At 12:08 p.m., the CNA returned and assisted the resident again. The CNA began to feed the resident at that time. On 12/3/25 at 10:25 a.m., the medical record of Resident 7 was reviewed. The resident was admitted to the facility on [DATE]. admission diagnoses included but were not limited to dementia (the loss of cognitive functioning thinking,…
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 · D2025-12-05 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
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 it was free of a medication error rate of greater than 5 percent for 1 of 4 residents (Resident 19) observed during the medication pass. There were 32 opportunities for error observed with 4 medication errors, resulting in a medication error rate of 12.5 percent. Findings include: On 12/3/25 at 9:31 a.m., Registered Nurse (RN) 12 administered medications to Resident 19. The medications included, but were not limited to, fluticasone-salmeterol aerosol (medication to ease breathing) inhaler 250-50 micrograms (mcg) 1 puff and tiotropium bromide inhaler (relaxes and opens air passages) aerosol 2.5 mcg 1 puff. RN 12 handed the resident the inhalers, and he took 1 puff of each. The resident did not rinse and spit after the fluticasone propionate inhaler and was not prompted by RN 12 to do so. The inhalers were administered one after the other, with no wait time between the two. Aspirin 81 milligrams (mg) and cetirizine 10 mg were not administered. At the same time, RN 12 indicated the resident was out 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 · D2025-12-05 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to document resident refusal or justification for holding insulin, and failed to document notification to the physician for 1of 1 resident reviewed for unnecessary medications (Resident 8). Findings include:On 12/04/25 at 10:00 a.m., the medical record of Resident 8 was reviewed. The resident was admitted to the facility on [DATE]. Diagnosis included but was not limited to, type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high). A quarterly Minimum Data Assessment (MDS), dated [DATE], indicated the resident was cognitively impaired and received daily insulin injections. A care plan, dated 11/22/22, indicated diabetes with risk for hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). Interventions included, but not limited to, antidiabetic medications per order, and notify physician and family as needed. A physician order, dated 7/24/25, indicated to administer Lantus SoloStar Solution…
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 before2025-12-05 · tag F0880 — failed to prevent and control infections — isolatedProvide 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, record review, and interview, the facility failed to ensure hand hygiene was performed during the medication pass for 3 of 4 residents reviewed on the medication pass (Residents 19, 26, and 67). Findings include: During a continuous medication pass observation, on 12/3/25 from 9:31 a.m. to 9:52 a.m., the following was observed. -Registered Nurse (RN) 12 prepared and administered medication to Resident 19. The medication included a nasal spray, two inhalers, and application of lidocaine patches (topical pain reliever). RN 12 wore gloves during the medication administration but did not perform hand hygiene before, or after, the medication administration. -RN 12 then prepared and administered medication to Resident 26. No hand hygiene was performed before or after the medication administration. -RN 12 then prepared and administered medication to Resident 67. The medication included eye drops. RN 12 wore gloves while administering the eye drops but did not perform hand hygiene before, or after, the medication administration. During an interview, on 12/3/25 at 9:56…
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 13 citations
- Potential for harm · Dcited before2025-05-15 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to honor a resident's preference regarding meal service for 1 of 3 records reviewed for quality of care (Resident C). Findings include: During a wound care observation on 5/14/25 at 1:59 p.m., accompanied by LPN 5 and the Assistant Director of Nursing (ADON), the resident indicated he had lunch in the dining room, but he would rather eat in his room. The staff made him go to the dining room for all meals. The ADON indicated to the resident that he knew why they liked him to go to the dining room and smiled at him. He indicated to the ADON that he could eat on his own without problems. The clinical record for Resident C was reviewed on 5/14/25 at 9:49 a.m. Diagnoses included hypertensive heart disease without heart failure, dysphagia, anxiety disorder, major depressive disorder, diabetes mellitus type II, and obesity. A significant change Minimum Data Set (MDS) assessment, dated 4/21/25, indicated the resident had was cognitively intact,…
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 · D2024-09-30 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a reweight was completed for a resident with a significant weight change for 1 of 3 residents reviewed for nutrition (Resident 47). Findings include: Resident 47's record was reviewed on 9/26/24 at 10:48 a.m. The profile indicated the resident's diagnoses included, but were not limited to, vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), chronic pain syndrome (symptoms beyond pain alone, like depression and anxiety, which interfere with one's daily life), and need for assistance with personal care. A physician's order, dated 1/27/22 indicated to provide the resident a general diet, regular texture, and thin liquids. A quarterly Minimum Data Set (MDS) assessment, dated 8/21/24, indicated the resident had severe cognitive deficit, was on a therapeutic diet, and had both a 5% or more in 1 month or 10% or more in 6 months weight loss and weight gain documented. A care plan, dated 7/8/22, indicated the resident was at increased nutritional…
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 · D2024-09-30 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a pharmacy recommendation had been addressed in a timely manner for 1 of 5 residents reviewed for unnecessary medications (Resident 35). Findings include: Resident 35's record was reviewed on 9/26/24 at 9:40 a.m. The profile indicated the resident's diagnoses included, but were not limited to, Alzheimer's disease late onset (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks that occurs after [AGE] years of age). A quarterly Minimum Data Set (MDS) assessment, dated 5/1/24, indicated the resident had severe cognitive deficit and received no scheduled or as needed (PRN) pain medication. A quarterly Minimum Data Set (MDS) assessment, dated 8/5/24, indicated the resident's cognitive status was unable to be assessed and she received no scheduled or PRN medication. A care plan, dated 12/2/23, indicated the resident had the potential for pain. Interventions included, but 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 · Dcited before2024-09-30 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure adequate sanitation of drinking glasses, pitcher, and kitchen equipment for 2 of 2 kitchen observations, and failed to ensure snacks were served in a sanitary manner for 1 of 1 random snack distribution observation. Finding includes: 1a. On 9/24/24 at 9:53 a.m., during initial kitchen tour, a thick white cloudy substance was observed on the inside surface of a 2-gallon pitcher. The pitcher was used to make lemonade, juice, and or tea for the residents. A thick cloudy substance was observed on a sink in the kitchen. The white substance was noted on the faucet base and went down into the inside of the sink. During an interview, on 9/25/24 at 10:41 a.m., Resident 21 indicated the plastic glasses that come from the kitchen were filthy and he did not like to drink out of them. During an interview, on 9/26/24 at 11:54 a.m., the Dietary Manager indicated she was aware of the facility having an issue with lime deposits on the plastic…
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 before2023-08-15 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY A. Based on observation, interview, and record review, the facility failed to ensure proper handwashing in the kitchen, and sanitary practices while pureeing foods and measuring the temperature of food to be served from the kitchen, during 4 of 4 kitchen observations. This deficient practice had the potential to effect 11 of 11 residents who received pureed food, and 63 of 63 residents who received food from the kitchen. B. Based on observations, interview, and record review, the facility failed to use proper hand hygiene when 3 certified nursing aides (CNA's) were observed assisting 6 residents to eat during 1 of 2 dining room observations (Residents 34, 36, 14, 30, 9, and 37). Findings include: A1. During a random continuous observation of the kitchen, on 8/7/23 from 10:07 a.m. to 10:31 a.m., Dietary Aide 5 was observed taking a soiled drinking pitcher from the dining room window and without wearing gloves, removed the soiled straw by the mouthpiece and tossed it in an open garbage container positioned…
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 before2023-08-15 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
A. Based on observation, interview, and record review, the facility failed to ensure proper handling of oral and eye drop medication for 2 of 2 residents observed during the medication administration observation (Residents 63 and 42). B. Based on observation, interview, and record review, the facility failed to ensure hand sanitization was performed in between glucometer blood testing for 3 of 3 residents observed during medication administration (Residents 52, 27, and 41). Findings include: A1. During a medication administration observation, on 8/10/23 at 9:14 a.m., RN 11 was administering eye drops to Resident 63. The RN administered the eye drops to the resident with her bare hands. The resident received a drop in each eye and the nurse touched underneath each eye with her bare finger. During an interview, on 8/10/23 at 11:40 a.m., Director of Nursing (DON) indicated she would need to pull the policy on rather staff were to wear gloves during eye drop administration. Resident 63's record was reviewed on 8/10/23 at 3:30 p.m. The profile indicated the resident's diagnosis included,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-15 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure residents' rights to privacy and dignity were maintained for 3 of 3 residents when completing blood glucose testing (Residents 27, 41, and 52). Findings include: 1. On 8/7/23 at 11:28 a.m., Resident 27 was observed propelling herself down the main hallway, when Licensed Practical Nurse (LPN) 4 asked Resident 27 to stop at the medication cart to complete a blood glucose test (measures how much sugar was in the blood). LPN 4 donned (put on) gloves, without sanitizing her hands, retrieved a glucometer (a device for measuring the concentration of glucose (sugar) in the blood by using a small drop of blood, placed on a disposable test strip in the glucometer) from the medication cart, cleaned the glucometer machine with a disinfectant wipe, and placed the glucometer directly onto the medication cart, without a barrier. LPN 4 cleaned Resident 27's finger with an alcohol pad, pricked the resident's finger with a lancet, obtained a blood sample, completed the glucometer reading, cleaned the resident's finger…
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 · D2023-08-15 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
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 provide comfortable water temperatures of more than 105 degrees Fahrenheit (F) and less than 115 degrees F in 8 of the 9 shared resident bathrooms on the secured memory care area observed for unsafe water temperatures. Findings include, During the initial tour, on 8/7/23 at 11:15 a.m., Resident 40 was observed standing at the sink in his shared bathroom. Steam was observed rising from the water, the resident indicated the water was too hot to touch. Water temperature was 129.6 Fahrenheit (F). Temperature with the Maintenance Director on 8/7/23 at 12:25 p.m. was 122.9 F. On 8/07/23 11:19 a.m., water temperature in the bathroom sink on the 100 hall was 129.0 F. A visitor observed steam rising from the water and the thermometer temperature and indicated it was too hot for Resident 63. On 8/07/23 at 11:36 a.m., water temperature in the bathroom sink shared between rooms [ROOM NUMBERS] was 130.6 F. Temperature with the Maintenance Director 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 · Dcited before2023-08-15 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the care plans were revised for concerns and interventions for 3 of 19 residents' care plans reviewed (Residents 14, 41 and 32). Findings include: 1. On 8/08/23 at 10:15 a.m., during initial observation Resident 14, did not have a palm pillow (layers of MicroSpring Textile rolled to 1 1/2 think pillow prevents digging fingernails into palms. Adjustable soft band with Velcro) applied to the contracted (a permanent shortening (as of muscle, tendon, or scar tissue) producing deformity or distortion) left hand. The fingernails on the left hand were long and jagged and were pressing into the palm of the hand. On 8/09/23 at 11:30 a.m., observed the resident sitting in a wheelchair in the main dining room. Palm pillow was not applied to the left hand. Fingernails on both hands were long and jagged. On 8/10/23 at 10:00 a.m., observed the resident sitting in a wheelchair. The call light was placed on the left side of her upper left arm. 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 · D2023-08-15 · 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 interview, the facility failed to trim the fingernails of a resident's contracted hand to prevent the nails from pressing into the palm of the hand for 1 of 24 residents reviewed for activities of daily living (Resident 14). Finding includes: On 8/08/23 at 10:15 a.m., during initial observation Resident 14, did not have a palm pillow (layers of MicroSpring Textile rolled to 1 1/2 think pillow prevents digging fingernails into palms. Adjustable soft band with Velcro) applied to the contracted (a permanent shortening (as of muscle, tendon, or scar tissue) producing deformity or distortion) left hand. The fingernails on the left hand were long and jagged and were pressing into the palm of the hand. On 8/09/23 at 11:30 a.m., observed the resident sitting in a wheelchair in the main dining room. Palm pillow was not applied to the left hand. Fingernails on both hands were long and jagged. On 8/10/23 at 10:00 a.m., observed the resident sitting in a wheelchair. The call light was placed on the left side of her upper left arm. The resident's left…
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 · D2023-08-15 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure medication was labeled properly for 2 of 2 medication carts and 1 of 2 medication storage rooms reviewed for medication storage (Resident 8 and 24), and the facility failed to ensure expired medications were disposed of for 1 of 2 medication storage rooms reviewed. Findings include: 1a. On 8/10/23 at 9:31 a.m., the closed unit medication cart contained 2 undated and opened insulin (medication used to lower blood sugar) pens. The insulin pens contained labels that indicated they were ordered for Resident 24. During an interview, on 8/10/23 at 9:32 a.m., Registered Nurse (RN) 11 indicated insulin pens were supposed to have an open date on them and were good for 28 days once they were opened. She was not aware of the date Resident 24's insulin pens were opened. She would dispose of the pens in the medication cart and get new ones from the medication storage refrigerator. Resident 24's record was reviewed on 8/10/23 at 10:03 a.m. The profile indicated the resident's diagnosis included, but were not limited…
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 · D2023-08-15 · tag F0826 — isolatedProvide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor.
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 observations, record review and interviews, the facility failed to ensure the licensed occupational therapist had the knowledge, competencies to enter a completed physicians order into the medical record of 1 of 24 residents reviewed (Resident 14). Finding Includes: On 8/8/23 at 10:15 a.m., during initial observation Resident 14 did not have a palm pillow (layers of MicroSpring Textile rolled to 1 1/2 think pillow prevents digging fingernails into palms. Adjustable soft band with Velcro) applied to the contracted (a permanent shortening (as of muscle, tendon, or scar tissue) producing deformity or distortion) left hand. The fingernails on the left hand were long and jagged and were pressing into the palm of the hand. On 8/9/23 at 11:30 a.m., observed the resident sitting in a wheelchair in the main dining room. Palm pillow was not applied to the left hand. Fingernails on both hands were long and jagged. On 8/10/23 at 10:00 a.m., observed the resident sitting in a wheelchair. The call light was placed 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 · D2023-08-15 · tag F0851 — isolatedElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to accurately report weekend staffing hours in the PBJ (payroll-based journal) reporting system for the 1 of 3 staffing quarters in 2023. Findings include: During review of the CASPER (Community Assessment for Public Health Emergency Response) report, on 8/11/23 at 9:00 a.m., the CASPER report indicated the facility had reported low weekend staffing and a 1-star staffing rate for the second quarter of 2023. During an interview, on 8/14/23 at 2:44 p.m., the Administrator (ADM) indicated she assisted in staff scheduling and the facility staffing was scheduled in-line with the PPD (Per Patient Day). She was not sure how the PBJ triggered low weekend staff and 1-star staffing. The PBJ information was inputted by the facility's corporate office. During an interview, on 8/15/23, the Administrator (ADM) indicated the facility did not have a policy regarding the PBJ reporting and the facility followed the state regulation regarding this. The deficient practice was corrected by 4/1/23, prior to the start of the survey and 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.
“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 INFINITY HEALTHCARE CONSULTING — 69 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 | 2 of 5 | 2.0 | ≈ chain avg |
| Health inspection | 1 of 5 | 2.1 | -1.1 vs chain |
| Staffing | 2 of 5 | 1.5 | +0.5 vs chain |
| Quality measures | 5 of 5 | 3.7 | +1.3 vs chain |
The other 68 homes this chain runs (chain average 2.0★, per CMS)
Showing 40 of 68; 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 | Share | Since |
|---|---|---|---|---|
| PUTNAM COUNTY HOSPITAL | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 05/23/2014 |
| ETIENNE, JENNIFER | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 04/11/2022 |
| WEATHERFORD, DENNIS | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 05/23/2014 |
| BRAY, ARNOLD | Individual | CORPORATE DIRECTOR | — | since 05/23/2014 |
| FRY, JANICE | Individual | CORPORATE DIRECTOR | — | since 05/23/2014 |
| HEADLEY, MATTHEW | Individual | CORPORATE DIRECTOR | — | since 05/23/2014 |
| LANDRY, KEITH | Individual | CORPORATE DIRECTOR | — | since 09/01/2020 |
| LEWIS, KATRINA | Individual | CORPORATE DIRECTOR | — | since 12/21/2022 |
| MANN, ROBERT | Individual | CORPORATE DIRECTOR | — | since 01/01/2016 |
| O'HAIR, DENNIS | Individual | CORPORATE DIRECTOR | — | since 05/23/2014 |
| COUNTY HOSPITAL MANAGER LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 05/23/2014 |
CMS files one row per role, so the 12 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 71% 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 $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 18% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Indiana Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 155202. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.