No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Springhurst Health Campus

628 N Meridian Rd, Greenfield, IN 46140 · Government - County · 74 certified beds · (317) 462-7067 Medicare & Medicaid certified

Call the home — (317) 462-7067 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Jun 20251 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$21,645 in federal fines
Insights

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

Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $21,645 in federal fines (most recent 2026-03-23)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

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

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

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

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
740 W Green Meadows Dr · (317) 318-7600 · Call to confirm hours
Pharmacy
Walgreens1.8 mi
1195 N State St · (317) 462-8923 · Call to confirm hours
Grocery
2212 W Main St · (317) 318-9328 · Call to confirm hours
Park
Typically dawn to dusk

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.3%11.0%15.4%better
Long-stay residents who lose too much weight2.2%5.5%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.7%1.1%2.0%better
Long-stay residents with depressive symptoms8.0%25.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.0%3.9%3.3%better
Long-stay residents whose ability to walk worsened7.8%11.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication28.3%23.5%18.9%worse
Long-stay residents given the seasonal flu vaccine85.4%95.4%95.3%worse
Long-stay residents with pressure ulcers0.7%3.6%4.7%better
Long-stay residents with worsening bladder/bowel control31.4%23.3%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table11.4%13.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine79.3%79.0%79.4%typical
Short-stay residents rehospitalized after admission17.3%22.2%22.6%better
Short-stay residents with an outpatient ER visit10.4%10.8%12.0%better
Long-stay hospitalizations per 1,000 resident days1.181.611.67better
Long-stay outpatient ER visits per 1,000 resident days1.951.441.80typical

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.

66.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 247 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

66.7%U.S. median 51.5%
Got home and stayed home
11.9%U.S. median 10.7%
Went back to hospital
78.0%U.S. median 56.6%
Met the expected recovery
0.48U.S. median 0.31
Therapy hours / resident / day
0.24hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.09hours / resident / day
Speech therapy

Met the expected recovery: 78.0% 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 109 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 0.48 therapist hours per resident per day in 2026Q1 — more than 79% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 25% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF66.7%CMS range 61.2–71.551.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.9%CMS range 9.2–14.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge78.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge67.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge63.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.7%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.8%CMS range 3.5–10.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.401.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

1.06
RN hours/ resident / day
0.85
LPN hours/ resident / day
2.40
Aide hours/ resident / day
4.30
Total nurse hours/ resident / day
0.78
RN hoursweekends
38.7%
Total nursing turnover
46.2%
RN turnover

How full it usually is: this home is certified for 74 beds and averages 55.9 residents a day — about 76% occupied, or roughly 18 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.30 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.06 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.40 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 3.69 hrs/resident/day on weekends vs 4.55 on weekdays — 19% thinner on weekends. RN hours go from 1.16 to 0.78 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 39% 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

10
deficiencies at the latest standard inspection (2025-06-17)
2
at the previous standard inspection (2024-04-30)

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.

ABCDEFGHIJKL

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

25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2026-03-23 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to correctly transcribe the hospital's discharge orders for 1 of 3 residents reviewed for accuracy of physician orders for a newly admitted resident. This deficient practice resulted in a resident not having a diagnosis of diabetes identified and not receiving his hospital discharged ordered insulin for five (5) days, which contributed to the resident having elevated (high) blood glucose, diminished cognitive levels, lethargy and being sent out to the local hospital. The resident was sent out to the local hospital on 2-13-26, at the request of the family. He was subsequently admitted to the local hospital the same date for altered mental status, possibly related to dehydration, infection or diabetic ketoacidosis. (Resident B) The Immediate Jeopardy began on 2/6/26 when the facility failed to correctly transcribe the hospital's discharge orders for a resident resulting in the resident not having a diagnosis of diabetes identified and not receiving his…

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

    Pharmacy Service Deficiencies · Past Non-Compliance
  • Potential for harm · F2025-06-17 · tag F0725 — failed to have enough nursing staff — widespread
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure sufficient nursing staff to provide activities of daily living (ADL) care, skin care treatments, and maintain residents' dignity. This deficient practice had the potential to affect 61 of 61 residents in the facility. Findings include: A confidential interview was conducted with a resident. They indicated there were not enough staff in the facility to help them. They forgot about them when they pressed their call light, and it made them feel unimportant. An interview was conducted with Resident P on 6/10/25 at 1:23 p.m. She indicated it took thirty minutes for staff to help her, after she pressed her call light. An interview was conducted with Resident S on 6/11/25 at 11:27 a.m. She indicated the facility was short staffed most of the time. An interview was conducted with Family Member 7 on 6/11/25 at 10:56 a.m. She indicated the facility was short staffed. The staff tried, but a lot of times, there was only one CRCA (Certified Resident Care Assistant) on duty for the hall, and one person couldn't do everything. The…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-17 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to assist dependent residents with shaving per preference and provide activities of daily living (ADL) care in a timely manner for 4 of 7 residents reviewed for activities of daily living. (Resident E, Resident G, Resident L, and Resident J) Findings include: 1. The clinical record for Resident E was reviewed on 6/16/2025 at 1:20 p.m. The diagnoses included, but were not limited to, urinary tract infection and depression. A Minimum Data Set (MDS) assessment, dated 5/14/2025, indicated Resident E was cognitively intact, utilized an indwelling urinary catheter, and needed substantial/maximal assistance with toileting hygiene, upper and lower body dressing, and personal hygiene. An activities of daily living care plan, revised 6/2/2025, indicated to offer Resident E shaving on shower days and as needed. Resident E's shower days were Monday and Thursday. A depression care plan for Resident E indicated the staff were to encourage the resident to voice their feelings and provide support. During an interview and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-17 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    2. The clinical record for Resident F was reviewed on 6/11/25 at 10:30 a.m. His diagnoses included, but were not limited to, Parkinson's disease. An interview was conducted with Family Member 4 on 6/11/25 at 10:38 a.m. She indicated there was an incident involving Resident F and CRCA (Certified Resident Care Assistant) 15 in March 2025 in his room. Resident F had bowel issues. It wasn't a happy situation, and CRCA 16 had to clean it up. CRCA 16 said it was gross right in front of him. They filed a grievance about it. Family Member 4 received a call back afterwards, stating the facility would be doing more staff training. The grievance log for the past six months was provided by Clinical Support on 6/12/25 at 10:48 a.m. There were only two grievances associated with Resident F, both dated 3/6/25, and both filed by Family Member 4. One was in regards to his room not being stocked with wipes, briefs, and trash bags, as there was an incident on 3/4/25, where none of these items were available. The grievance was resolved by the DHS (Director of Health Services.) The other grievance was…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-17 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure a resident's call light was within reach for 1 of 1 resident reviewed for call light accessibility. (Resident 218) Findings include: During an observation and interview with Resident 218 on 6/11/25 at 9:59 a.m., Resident 218 was sitting in a wheelchair in the middle of her room. The call light was on the other side of the room on the floor beside her bed. Resident 218 indicated when staff would get her up during the day, she could never reach her call light and had no way of contacting staff when she needed help. She indicated every night she would get anxious before bed because staff would shut her door and she's not sure if she would have her call light or not, and if not, she had no way of contacting staff and had to yell out for help. During an observation and interview with Resident 218 on 6/12/25 at 10:15 a.m., Resident 218 was sitting in her wheelchair in the middle of her room. The call light was on the opposite side of the bed across the room. Resident 218 indicated she was glad someone came…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-17 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to immediately report an allegation of abuse to the ED (Executive Director) and IDOH (Indiana Department of Health) for 2 of 2 residents reviewed for abuse. (Resident D and Resident H) Findings include: 1. The clinical record for Resident H was reviewed on 6/10/25 at 12:11 p.m. His diagnoses included, but were not limited to, dementia. The 6/2/25 admission Minimum Data Set (MDS) assessment indicated he was severely cognitively impaired. The 6/11/25 care plan indicated he expressed interest in compassionate touching and did not have capacity to give consent. The 6/6/25, 9:30 p.m. nurse's note for Resident H, recorded as a late entry on 6/7/25 at 7:45 a.m. by RN (Registered Nurse) 5, indicated, Resident was found in other residents room both were in w/c's [wheelchairs,] he was observed to have his hand on her leg and one on her shoulder. Residents were told that they need to be in common area with staff members and not in each others rooms. Both residents compliant with redirection. No injury noted, physically or…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-17 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to identify and initiate a thorough investigation into an alleged violation of abuse for 2 of 2 residents reviewed for abuse. (Residents D and H) Findings include: 1. Resident D's 6/6/25, 9:30 p.m. nurse's note, recorded as a late entry on 6/7/25 at 7:45 a.m. by RN 5, indicated Resident was found in other residents room both were in w/c's, he was observed to have his hand on her leg and one on her shoulder. Residents were told that they need to be in common area with staff members and not in each others rooms . Both residents compliant with redirection. No injury noted, physically or mentally. ADHS notifie Resident D's 6/9/25, 4:38 p.m. IDT (Interdisciplinary Team) note, written by the DHS (Director of Health Services) indicated, Patient reviewed for visiting with other resident. Other resident entered room and they were having a conversation. He had his land on her leg and another on her shoulder. Patient is social and friendly. Encouraged to visit in common areas as she is confused at baseline. Patient…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-17 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review, the facility failed to timely transmit a Quarterly Minimum Data Set (MDS) assessment for 1 of 9 residents reviewed for MDS Assessments. (Resident 21) Findings include: The clinical record for Resident 21 was reviewed on 6/16/2025 at 11:40 a.m. The diagnosis included, but was not limited to, dementia. A Quarterly MDS assessment, had an assessment reference date (ARD) of 5/9/2025. This assessment was completed on 5/22/2025. An MDS transmission report, provided on 6/16/2025 at 2:20 p.m., indicated the Quarterly MDS assessment for Resident 21 with an ARD of 5/9/2025 was transmitted on 6/13/2025. During an interview, on 6/16/2025 at 1:35 p.m., MDS Support indicated they utilize the RAI (Resident Assessment Instrument) Manual for guidance on timeliness of MDS Assessments. For Quarterly assessments, they have 14 days to transmit the completed assessments, but this was not done because she was busy with end of month activities.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-17 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    3. The clinical record for Resident Q was reviewed on 6/11/25 at 11:00 a.m. The diagnoses included, but were not limited to, overactive bladder and urinary tract infection. An interview and observation were conducted with Family Member 7 on 6/11/25 at 11:05 a.m. She indicated Resident Q had a history of UTIs (urinary tract infections.) During her most recent care plan meeting a couple of weeks ago, they discussed Resident Q having a possible allergy to Bactrim, an antibiotic medication used to treat UTIs. The staff at the care plan meeting said they would chart it, but she wasn't sure what happened, because she was just prescribed it again a couple of days ago, and Resident Q's lips swelled up, like they did in April 2025, when she was prescribed it. At this time, Family Member 7 displayed two photographs on her cell phone. One, dated 4/13/25 at 11:38 a.m., was Resident Q with a very red, swollen, bottom lip. Family Member 7 indicated Resident Q had to have a cream applied to her lips for it. The other photograph, dated 6/9/25 at 7:44 p.m., was of Resident Q with a red, swollen,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-17 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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

    Based on interview, observation, and record review, the facility failed to ensure a resident's catheter drainage bag and tubing were free of contact with the floor for 1 of 2 residents reviewed for catheters. (Resident E) Findings include: The clinical record for Resident E was reviewed on 6/16/2025 at 1:20 p.m. The diagnoses included, but were not limited to, urinary tract infection and depression. A Minimum Data Set Assessment, dated 5/14/2025, indicated Resident E was cognitively intact, utilized an indwelling urinary catheter, and needed substantial/maximal assistance with toileting hygiene, upper and lower body dressing, and personal hygiene. A care guide care plan, initiated on 6/27/2024 and revised 6/13/2025, indicated to ensure Resident E's indwelling catheter did not touch the floor. A physician's order, dated 3/20/2025, indicated Resident E utilized an indwelling urinary catheter for neurogenic bladder. During an interview and observation, on 6/10/2025 at 1:59 p.m., Resident E was sitting in his wheelchair. The urinary catheter drainage bag and tubing were contacting the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-17 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow hospital discharge orders to discontinue medication upon readmission for 1 of 4 residents reviewed for quality of care. (Resident J) The clinical record for Resident J was reviewed on 6/12/25 at 10:04 a.m. The diagnoses included, but were not limited to, anemia and atrial fibrillation. During an interview with Resident J on 6/11/25 at 12:51 p.m., Resident J indicated she had just returned from the hospital yesterday after having blood loss and thought she had been told they were going to hold all of her blood thinners for a while. The admission Minimum Data Set (MDS) assessment, dated 5/9/25, indicated Resident J was cognitively intact. The hospital Discharge summary, dated [DATE], was provided by MDS Support on 6/12/25 at 12:57 p.m. It indicated Resident J had a discharge diagnosis of acute blood loss anemia and discontinue aspirin 81 mg po (by mouth) daily. The Medication Administration Record (MAR) for June 2025, indicated aspirin 81 mg po…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · Dcited before2024-04-30 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to promote a resident's dignity by telling Resident H to utilize an incontinence brief instead of a bedpan, and a staff member cursed within hearing distance of Resident F. This affected 2 of 3 residents reviewed for dignity. Findings include: 1. Resident F's record was reviewed on 4/26/24 at 11:03 a.m. The record indicated Resident F had diagnoses that included, but were not limited to, metabolic encephalopathy, heart disease, atrial fibrillation, type 2 diabetes, violent behavior, speech disturbances, and vascular dementia, severe, with psychotic disturbance. An admission Minimum Data Set assessment, dated 1/19/24, indicated Resident F was severely cognitively impaired, is sometimes understood, rarely/never understood, had physical behavior symptoms directed toward others (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurred 1 to 3 days. Had other behavioral symptoms not directed toward others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-30 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide showers as scheduled for 2 of 4 residents reviewed for activities of daily living. (Residents K and B) Findings include: 1. On 4/23/24, at 2:39 p.m., Resident K indicated she doesn't get her showers like she is supposed to, that she doesn't get her showers twice a week; staff will come in at 9 p.m. and she doesn't want one then. She is supposed to get showers on Wednesday and Saturday after 6 p.m. Resident K's record was reviewed, on 4/25/24, at 1:19. The record indicated Resident K was admitted with diagnoses that included, but were not limited to, metabolic encephalopathy, severe sepsis with septic shock, acute respiratory failure with hypoxia, acute kidney failure, chronic obstructive pulmonary disease, osteoarthritis, low heart rate, and high blood pressure. An admission Minimum Data Set assessment, dated 2/20/24, indicated Resident K was cognitively intact, required substantial/maximal assistance for shower or bathing, and it was very…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-27 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide Resident 207 with a Notification of Medicare Non-Coverage (NOMNC) at least two calendar days prior to discharge from Medicare Part A services for 1 of 3 beneficiary notices reviewed. Findings include: The clinical record for Resident 207 was reviewed on 2/23/2023 at 1:15 p.m. Resident 207 started Medicare Part A services on 11/29/2022 and the last covered day of Part A services was 1/3/2023. A NOMNC with a last covered day of Medicare Part A services was dated for 1/3/2023 and was signed by Resident 207 on 1/3/2023. An interview with the Executive Director on 2/24/2023 at 3:57 p.m., indicated the facility was unable to provide a notice that Resident 207 was aware of Medicare Part A services to be discontinued prior to the NOMNC and he was unable to explain why Resident 207 was not given the NOMNC sooner. A policy entitled, NOMNC Completion SOP [Standard Operating Procedure], was provided by the Clinical Support on 2/24/2023 at 11:05 a.m. The policy indicated, .For residents being notified of discontinuation 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-27 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    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 provide written bed hold information for 1 of 2 residents reviewed for hospitalization. (Resident 15) Findings include: Resident 15's record was reviewed on 2/22/23 at 1:23 p.m. The record indicated Resident 15 had diagnoses that included, but were not limited to, liver disease, type 2 diabetes mellitus, urinary tract infection, heart failure, heart disease, anxiety and depression. A Quarterly Minimum Data Set (MDS) assessment, dated 1/4/2023, indicated Resident 15 was cognitively intact. Progress notes, dated 12/26/22 at 12:33 a.m., indicated Resident 15 was transported to a local hospital. Census documentation indicated the resident was sent to the hospital on [DATE] and returned on 12/30/22. There was no documentation in the clinical record that indicated a bed hold notice was provided to the resident or family upon discharge to the hospital. During an interview, on 2/24/23 at 2:45 p.m., the Director of Health Services indicated she could not find…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-27 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to complete a care plan meeting for 1 of 1 resident's reviewed for care plan meetings (Resident 43). Finding include: During an interview with Resident 43 on 2/20/23 at 2:04 p.m., indicated he had not had care plan meeting where the facility talked to him about his goals and needs. Review of the record of Resident 43 on 2/23/23 at 11:20 a.m., indicated the resident's diagnoses included, but were not limited to, severe sepsis with septic shock, acute kidney failure, pulmonary fibrosis, Parkinson disease, hypertension, type two diabetes mellitus, low back pain, right and left knee contractures, prostate cancer, chronic pain, insomnia, muscle weakness and urinary retention. The Annual Minimum Data Set (MDS) assessment for Resident 43, dated 11/11/22, indicated the resident was cognitively intact for daily decision making. During an interview with the Director Of Health Services (DHS) on 2/23/23 at 11:55 a.m., indicated Resident 43 had not had a care plan meeting since April 2022. The DHS indicated she was unsure how the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-27 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to provide showers as scheduled for dependent residents for 2 of 2 reviewed for Activities Of Daily Living (ADL) ( Resident 30 and Resident 9). Findings include: 1.) During an interview with Resident 30 on 2/20/23 at 11:46 a.m., the resident indicated she was not receiving two showers a week like she was suppose to. The resident indicated she used wipes to clean herself the best she could. The resident indicated she had not had her hair washed for seven days. During an interview with Resident 30 on 2/23/23 at 1:58 p.m., the resident indicated when she was home she took at least three showers a week. The resident indicated she would be glad when she was able to give herself a shower so she wasn't a burden on the staff. I did get a shower on Monday. Review of the record of Resident 30 on 2/23/23 at 2:10 p.m., indicated the resident's diagnoses included, but were not limited to, hypertensive heart disease, occlusion of arteries, peripheral vascular disease, chronic obstructive pulmonary disease, lack of coordination,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-27 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure collaboration with a hospice provider regarding coordination of care related to laboratory work, medication form changes, wound assessments, and Registered Dietitian (RD) recommendations for 1 of 1 resident reviewed for hospice services (Resident 17), 1 of 5 residents reviewed for pressure ulcers (Resident 22), and 1 of 1 resident reviewed for nutrition (Resident 26). The facility also failed to ensure a device was in place, per physician orders, in regard to limited range of motion (ROM) for 1 of 1 resident reviewed for impaired mobility (Resident 22). Findings include: 1a. The clinical record for Resident 17 was reviewed on 2/24/23 at 11:26 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, anxiety disorder, chronic kidney disease, and unspecified convulsions. A safety care plan, revised 2/17/23, indicated Resident 17 was at risk for seizures related to diagnosis of unspecified convulsions. The approach was listed to do any laboratory work per physician orders and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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 observation, interview, and record review, the facility failed to ensure weekly measurements were conducted of pressure ulcers, provide treatment as ordered by the physician, and ensure a resident with a history of pressure ulcers didn't stay in the same position for an extended period of time for 2 of 5 residents reviewed for pressure ulcers. (Resident 17 and Resident 22) Findings include: 1. The clinical record for Resident 17 was reviewed on 2/22/23 at 10:50 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, unspecified protein-calorie malnutrition, anxiety disorder, and unspecified convulsions. A progress note, dated 2/15/23 at 3:44 p.m., indicated Resident 17 had an area to the left hip that appears to look like an old scar. A new red blanchable area was noted on her right hip. Resident was very thin and has multiple bony prominences noted. The hospice nurse was present and verbalized to continue to change position. A care plan for skin integrity, revised 2/21/23, indicated Resident 17 was at risk for pressure ulcers related 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure fall interventions were in place per the care plan and ensure a fall follow-up included completed neurological checks for 3 of 4 residents reviewed for accidents. (Resident 17, 31, and 9) Findings include: 1a. The clinical record for Resident 17 was reviewed on 2/22/23 at 10:50 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, malnutrition, anxiety disorder, and unspecified convulsions. A fall care plan, revised 2/17/23, indicated Resident 17 was at risk for falling with the approach to provide resident with a blanket while up in broda chair and staff to recline broda chair after meals. An observation conducted, on 2/23/23 at 12:35 p.m., of Resident 17 being assisted by a staff member in her broda chair and set her in her broda chair in the common area on the hallway where she resided in front of the television. The broda chair was not positioned in a recline position and Resident 17 was sitting upwards. An observation conducted, on 2/24/23 at 10:00 a.m., of Resident…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-27 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to follow up with a Registered Dietitian (RD) recommendations for a supplement for a resident who experienced significant weight loss for 1 of 1 resident reviewed for nutrition. (Resident 26) Findings include: The clinical record for Resident 26 was reviewed on 2/22/23 at 12:44 p.m. The diagnoses included, but were not limited to, history of COVID-19, history of pneumonia, congestive heart failure (CHF), dysphagia, anemia, and cerebrovascular disease. A care plan for nutritional status, revised 2/18/23, indicated Resident 26 was malnourished and/or at risk for malnutrition related to diagnoses, inadequate nutrient/energy intakes, and/or metabolic demands. The approach was to have the Dietitian to re-evaluate as indicated and provide diet, supplements, medications, and adaptive equipment as ordered. A Registered Dietitian (RD) note, dated 2/21/23 at 3:26 p.m., indicated the following, .Noted COVID+ [positive] on 2/6/23 with decline. Noted significant weight loss since 2/6/23 with poor meal intake. Noted new impairments 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-27 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to store oxygen nasal cannula and C- PAP mask in a bag for infection control purposes and failed to date oxygen tubing for 2 of 2 residents reviewed for respiratory care (Resident 45 and Resident 163). Findings include: 1.) During 2/20/23 at 11:03 a.m., Resident 45 was sitting in her wheelchair with oxygen on via oxygen concentrator with a nasal cannula. The resident's C - pap mask was not in a bag and not dated. oxygen concentrator on 2 liters tubing on either one was not dated. The portable oxygen on back of wheelchair nasal cannula not bagged and touching the back on the wheelchair, the tubing was not dated. During an observation and interview on 2/22/23 at 11:07 a.m., Resident 45 indicated the staff do not always put the C-PAP mask in a bag, it depended on who was working. The resident's oxygen nasal cannula was laying on the floor from her portable oxygen tank, not in a bag. Review of the record of Resident 45 on 2/24/23 at 2:00 p.m , indicated the resident's diagnoses included, but were not limited to, acute…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-27 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure 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 interview and record review, the facility failed to ensure a pharmacy recommendation was followed up with timely for 2 of 5 residents reviewed for unnecessary medications. (Resident 31 and Resident 9) Findings include: 1. The clinical record for Resident 31 was reviewed on 2/23/23 at 1:53 p.m. The diagnoses included, but were not limited to, dementia, heart disease, atrial fibrillation, anemia, and major depressive disorder. A physician order, dated 1/13/22, was noted for Acetaminophen PM (diphenhydramine-acetaminophen) tablet 25-500 milligrams at bedtime. A pharmacy recommendation, dated 9/22/22, indicated the following, .He is receiving Tylenol PM QHS [at bedtime] for insomnia. Diphenhydramine is included in the Beers list for potentially inappropriate medications in the elderly due to the anticholinergic properties. Would it be possible to replace this with Trazodone 50mg [milligrams] QHS? The document indicated the physician agreed with all recommendations. Another pharmacy recommendation, dated 11/16/22, indicated the following, .The pharmacy event from 9/22 was closed…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-27 · tag F0790 — failed to provide dental care — isolated
    Provide routine and 24-hour emergency dental care for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to provide routine dental services for a resident who had missing or broken teeth and difficulty chewing, for 1 of 2 residents reviewed for dental status (Resident 15). Findings include: During an interview, on 2/21/23, Resident 15 indicated he has several teeth that are broken or worn down and he has trouble eating, especially meat. Observation of the resident's teeth indicated he had several missing or broken upper and lower teeth. Resident 15's record was reviewed on 2/22/23 at 1:23 p.m. The record indicated Resident 15 had diagnoses that included, but were not limited to, liver disease, type 2 diabetes mellitus, heart failure, heart disease, anxiety and depression. A Quarterly Minimum Data Set (MDS) assessment, dated 1/4/2023, indicated Resident 15 was cognitively intact. A care plan, dated 12/8/22 indicated a problem for potential for mouth pain related to missing teeth. His goal was not to exhibit mouth pain or infection. Interventions included, but were not limited to, dental evaluation and intervention as…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-27 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure medications were not handled by bare hands during a medication administration observation. This affected 1 of 3 residents observed for a medication pass. (Resident 45) Findings include: During a medication administration observation, on 2/20/23 at 7:25 a.m. RN 1 was observed as she prepared Resident 45's morning medications. The following medications were set up for Resident 45: amiodarone 200 milligrams (mg) 1 tablet, aspirin 81 mg 1 tablet, Eliquis 5 mg 1 tablet, Ferrous sulfate 325 mg 1 tablet, hydroxychloroquine 200 mg 1 tablet, Mucinex 600 mg 1 tablet, pantoprazole 40 mg 1 tablet, potassium chloride 20 milieu, 2 tablets given to equal 40 mg, sildenafil 20 mg 1, torsemide 20 mg 1, Prednisone 10 mg 1, and oyster shell calcium 500 mg with vitamin D 200 units, 1 tablet. RN 1 was observed to pop the pills out of the package onto her ungloved hands before she placed them in a medication cup, then crushed the pills and placed them in applesauce. A capsule for Keflex 500 milligrams, and a capsule 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$21,645 in federal fines across 1 penalty.

  • $21,645 — penalty dated 2026-03-23

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to TRILOGY HEALTH SERVICES — 123 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 54.2-1.2 vs chain
Health inspection 2 of 53.5-1.5 vs chain
Staffing 3 of 53.3-0.3 vs chain
Quality measures 5 of 54.8+0.2 vs chain
The other 122 homes this chain runs (chain average 4.2★, per CMS)
1 of 5Heritage TheFindlay, OH 1 of 5The Oaks Rehabilitation and Healthcare CenterZanesville, OH 2 of 5Homewood Health CampusLebanon, IN 2 of 5Violet Springs Health CampusPickerington, OH 2 of 5Woodmont Health CampusBoonville, IN 3 of 5Cobblestone Crossings Health CampusTerre Haute, IN 3 of 5Creasy Springs Health CampusLafayette, IN 3 of 5Cumberland Pointe Health CampusWest Lafayette, IN 3 of 5Forest Park Health CampusRichmond, IN 3 of 5Franciscan Health Care CenterLouisville, KY 3 of 5Greenleaf Health CampusElkhart, IN 3 of 5River Terrace Health CampusMadison, IN 3 of 5Scenic Hills At The MonasteryFerdinand, IN 3 of 5Smiths Mill Health CampusNew Albany, OH 3 of 5Springs Of Richmond, TheRichmond, IN 3 of 5St Mary Healthcare CenterLafayette, IN 3 of 5Stonegate Health CampusLapeer, MI 3 of 5Sun Prairie Senior LivingSun Prairie, WI 3 of 5Taylor Springs Health CampusGahanna, OH 3 of 5The Willows at Fritz FarmLexington, KY 3 of 5The Willows at HamburgLexington, KY 3 of 5The Willows at HarrodsburgHarrodsburg, KY 3 of 5The Willows at SpringhurstLouisville, KY 3 of 5Villages At Oak Ridge, TheWashington, IN 3 of 5Waunakee Valley Senior LivingWaunakee, WI 3 of 5Wellbrooke Of CarmelCarmel, IN 4 of 5Arlington Place Health CampusIndianapolis, IN 4 of 5Ashford Place Health CampusShelbyville, IN 4 of 5Aspen Place Health CampusGreensburg, IN 4 of 5Avalon Springs Health CampusValparaiso, IN 4 of 5Bethany Pointe Health CampusAnderson, IN 4 of 5Blair Ridge Health CampusPeru, IN 4 of 5Bridgepointe Health CampusVincennes, IN 4 of 5Cedar Creek Health CampusLowell, IN 4 of 5Clearvista Lake Health CampusIndianapolis, IN 4 of 5Forest Springs Health CampusLouisville, KY 4 of 5Glen Oaks Health CampusNew Castle, IN 4 of 5Glen Ridge Health CampusLouisville, KY 4 of 5Meadows Of Delphos TheDelphos, OH 4 of 5Meadows Of Ottawa TheOttawa, OH

Showing 40 of 122; 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 / managerTypeRoleShareSince
HANCOCK REGIONAL HOSPITALOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 11/01/2014
TRILOGY OPCO LLCOrganizationDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 02/10/2026
TRILOGY PROPCO FINANCE LLCOrganizationDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 12/01/2015
AMERICAN HEALTHCARE REIT HOLDINGS LPOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 10/01/2021
AMERICAN HEALTHCARE REIT INCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 10/01/2018
GAHC3 TRILOGY JV LLCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 12/01/2015
GAHC4 TRILOGY JV LLCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 10/01/2018
TRILOGY HEALTH SERVICES LLCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 12/01/2015
TRILOGY HEALTHCARE HOLDINGS INCOrganizationINDIRECT OWNERSHIP INTERESTsince 12/01/2015
TRILOGY INVESTORS LLCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 12/01/2015
TRILOGY PROPERTY HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 12/01/2015
TRILOGY REAL ESTATE INVESTMENT TRUSTOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 12/01/2015
TRILOGY REIT HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 12/01/2015
ORIX REAL ESTATE CAPITAL LLCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 01/01/2023
BOND, MARIAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 07/01/2021
CLARK, TIMOTHYIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 05/01/2015
DAUGHERTY, JOSHUAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 01/01/2020
FELKER, DEANIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 05/01/2015
JOYNER, SARAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 01/01/2022
LONG, STEVENIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 06/13/2022
WILLARD, LACEYIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 05/01/2015
WILSON, ROYIndividualCORPORATE DIRECTORsince 11/01/2014
TRILOGY HEALTHCARE OF GREENFIELD, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/10/2026
HAFIDH, SAADIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/15/2025
WILSON, KEITHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/17/2024
BARNEY, LEIGHIndividualLIMITED PARTNERSHIP INTEREST; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 02/10/2026
DAVIS, DAVIDIndividualLIMITED PARTNERSHIP INTERESTsince 12/31/2019
PARAGON OUTPATIENT REHABILITATION SERVICES LLCOrganizationADP OF THE SNFsince 12/01/2015
TRILOGY HEALTHCARE MASTER TENANT V, LLCOrganizationADP OF THE SNFsince 02/10/2026
TRILOGY HEALTHCARE OF HANCOCK II, LLCOrganizationADP OF THE SNFsince 12/01/2015
TRILOGY MANAGEMENT SERVICES LLCOrganizationADP OF THE SNFsince 12/01/2015
TRILOGY PRO SERVICES LLCOrganizationADP OF THE SNFsince 02/10/2026

CMS files one row per role, so the 58 rows in the source record cover these 32 parties — each is shown once here with every role it holds. Nothing is omitted.

20 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$15.1M
Net patient revenuemost recent cost report
+15.6%
Operating marginrevenue minus expenses
$1.8M
Related-party expense14% of expenses
Who pays — share of resident-days
Medicaid 17%Medicare 18%Other / private 64%

This home reported $1.8M paid to related parties — landlords or management companies under common ownership — equal to about 14% 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

$326per resident / day
operating cost
$9,914per month
≈ monthly operating cost
$386per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IN

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Indiana Medicaid page.

Typical monthly cost in Indiana
$8,943/mo
Nursing home (semi-private)
$10,326/mo
Nursing home (private)
$5,639/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 155767. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-17, 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.

What to do next