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Willows Of Greensburg

410 Park Rd, Greensburg, IN 47240 · Government - City/county · 100 certified beds · (812) 663-7543 Medicare & Medicaid certified

Call the home — (812) 663-7543 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Nov 2024Behavioral-health or dementia-care citation — no harm found (F0740)
Insights

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

In its favor
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing 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.

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
813 N Lincoln St · (765) 717-5399 · Call to confirm hours
Pharmacy
1512 N Lincoln St · (812) 663-2756 · Call to confirm hours
Grocery
736 W Main St · (812) 663-9411 · Call to confirm hours
Park
(812) 663-3131 · Typically dawn to dusk
Place of worship
FBC Youth0.6 mi
209 W Washington St · (812) 663-3778

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 2 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 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 rating2★
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 increased9.4%11.0%15.4%better
Long-stay residents who lose too much weight11.4%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.5%0.4%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection2.2%1.1%2.0%typical
Long-stay residents with depressive symptoms74.9%25.2%6.5%worse 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 injury7.7%3.9%3.3%worse
Long-stay residents whose ability to walk worsened9.5%11.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication25.8%23.5%18.9%worse
Long-stay residents given the seasonal flu vaccine96.6%95.4%95.3%typical
Long-stay residents with pressure ulcers3.5%3.6%4.7%better
Long-stay residents with worsening bladder/bowel control21.7%23.3%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table23.0%13.6%17.1%worse
Short-stay residents who newly got an antipsychotic medication6.0%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine90.2%79.0%79.4%better
Short-stay residents rehospitalized after admission20.1%22.2%22.6%better
Short-stay residents with an outpatient ER visit24.7%10.8%12.0%worse
Long-stay hospitalizations per 1,000 resident days0.861.611.67better
Long-stay outpatient ER visits per 1,000 resident days1.751.441.80typical

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.

10.3%U.S. median 10.7%
Went back to hospital
66.7%U.S. median 56.6%
Met the expected recovery
0.29U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 66.7% 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 24 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 0.29 therapist hours per resident per day in 2026Q1 — more than 46% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.3%CMS range 6.5–16.910.7%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 discharge66.7%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 discharge70.8%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 discharge66.7%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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.831.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.46
RN hours/ resident / day
0.77
LPN hours/ resident / day
2.95
Aide hours/ resident / day
4.18
Total nurse hours/ resident / day
0.23
RN hoursweekends
53.2%
Total nursing turnover
70.0%
RN turnover

How full it usually is: this home is certified for 100 beds and averages 71.3 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 4.18 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.95 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 3.81 hrs/resident/day on weekends vs 4.33 on weekdays — 12% thinner on weekends. RN hours go from 0.56 to 0.23 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 53% 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

7
deficiencies at the latest standard inspection (2026-05-20)
10
at the previous standard inspection (2025-04-07)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

30 citations, most serious first. The 10 most serious are shown; the remaining 20 are one tap away and print in full.

  • Potential for harm · E2026-05-20 · tag F0925 — failed to control pests — pattern
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    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 an effective pest control program was maintained and the kitchen was free of mouse droppings. This deficient practice had the potential to affect 71 of 71 residents residing in the facility. Findings include:During the initial kitchen tour with the Dietary Manager (DM), on 05/14/2026 at 10:45 A.M., the following was observed in the dry storage room: -Scattered mouse droppings in a case box of cans of evaporated milk that was sitting on a wire shelf rack,-Scattered mouse droppings in a metal tray under the furnace, and-Scattered mouse droppings in an open clear rectangular bin full of plastic lids that was sitting on a wire shelf rack. During an observation and interview with the DM, on 05/15/2026 at 2:04 P.M., the DM indicated the pest control company had been to the facility for treatment a couple of weeks ago. During an interview, on 05/15/2026 at 2:07 P.M., the Administrator indicated the facility used a local pest control company and last date of service was 05/01/2026 when they provided 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-20 · 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 record and interview, the facility failed to follow the physician's hold parameters for a cardiac medication for 1 of 19 residents reviewed for quality of care. (Resident 63)Findings include:Resident 63's clinical record was reviewed on 05/19/2026 at 1:20 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 12/17/2025, indicated the resident's diagnosis include, but were not limited to: hypertension (high blood pressure).The resident's current physician's orders, with a start date of 03/31/2023, indicated the resident was prescribed amlodipine (hypertension), 10 milligrams every morning. The medication was to be held if the resident's systolic blood pressure (the top number) was below 110. The April and May 2026 Electronic Medication Administration Record (EMAR) indicated the medication was administered on the following days when the resident's blood pressure was below 110:- On 04/01/2026, the resident's systolic blood pressure was 90,- On 04/02/2026, the resident's systolic blood pressure was 90,- On 04/04/2026, the resident's systolic blood pressure was 103,- On…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-20 · 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, record review, and interview, the facility failed to ensure wound treatments were completed as ordered for 2 of 3 residents reviewed for pressure ulcers. (Residents 54 and 63)Findings include:1. During an observation, on 05/19/2026 at 10:18 A.M., the Assistant Director of Nursing (ADON) prepared supplies to complete Resident 54's wound treatment. She placed a towel on the overbed table, arranged the supplies on top of it, washed her hands, and donned gloves. She elevated the resident's bed to waist level, rolled the resident to her left side, removed the resident's pants, and unfastened her brief. She then removed her gloves, sanitized her hands, and donned new gloves. The ADON removed the resident's dressing from the right ischium, which had drainage present and was dated for the previous day. She cleansed the wound with Dakin's solution. The wound was approximately tennis ball size, and had measurable depth. The wound contained slough (non-viable yellow, tan, gray, green, or brown tissue; usually moist, can be soft, stringy, and mucinous in texture. Slough…

    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 before2026-05-20 · 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 observation, record review, and interview, the facility failed to follow infection control guidelines related to enhance barrier precautions for 1 of 2 residents reviewed for urinary tract infections. (Resident 25)Findings include:During an observation on, 05/19/2026 at 1:26 P.M., Certified Nurse Aide (CNA) 7 was in Resident 25's room. She donned gloves and pulled the curtain closed. She removed the resident's blankets and brief. She cleansed the resident and the resident's urinary catheter appropriately. She did not don a gown to provide care to the resident. The resident's door contained signs that indicated there was enhanced barrier precautions (infection control measures designed to stop the spread of dangerous germs) in place. The sign listed that the staff were to wear gown and gloves when providing care. The clinical record for Resident 25 was reviewed on 05/18/2026 at 9:52 A.M. The resident was severely cognitively impaired. The resident's diagnosis included but was not limited to neurogenic bladder (a lack of bladder control due to nerve damage in the brain,…

    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 before2026-05-20 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to obtain weights for 1 of 3 residents reviewed for nutrition. (Resident 7)Findings include:The clinical record for Resident 7 was reviewed on 05/18/2026 at 11:41 A.M. A Significant Change Minimum Data Set (MDS) assessment, dated 04/22/2026, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, heart failure (a chronic condition where the heart muscle cannot pump blood efficiently enough to meet the body's needs) and respiratory failure (occurs when your lungs cannot get enough oxygen into the blood or fail to remove enough carbon dioxide from it). An open-ended physician's order, with a start date of 04/22/2026, indicated the resident was to be given Bumetanide (a diuretic) 2 milligrams, every 24 hours as needed for leg swelling or a weight gain of greater than 3 pounds in one day. The clinical record and the April and May 2026 Electronic Medication Administration Record/Electronic Treatment Administration Record lacked the resident had documented weights from…

    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 before2026-05-20 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure 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 and interview, the facility failed to ensure multi use insulin pens had the required labeling for 2 of 3 medication carts reviewed (Long Hall Medication Cart and L Hall Medication Cart).Findings include: 1. On 05/20/2026 at 2:31 P.M., the Long Hall Medication Cart was observed with Licensed Practical Nurse (LPN) 2 and contained the following: - A Lantus (a type of long-acting insulin) insulin pen for Resident 1. The pen was around eighty percent full and was not labeled with an opened on date.During an interview, on 05/20/2026 at 2:32 P.M., LPN 2 indicated whoever put the pen in the cart should have dated the pen. She used the insulin pen to administer 50 units of insulin to Resident 1 that morning. The insulin pen should be labeled with the date it was opened. 2. On 05/20/2026 at 2:35 P.M., the L-Hall Medication Cart was observed with LPN 3 and contained the following:- A Basaglar (a type of long-acting insulin) insulin pen for Resident 73. The pen was half full and was not labeled with an opened on date.The current, undated facility policy, titled Labeling 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-20 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to store foods appropriately for 2 of 3 snack refrigerators reviewed. (Memory Care Unit and Station 4) Findings include: During an observation and interview, on 05/20/2026 at 2:46 P.M., with QMA (Qualified Medication Aide) 4, the snack refrigerator on the Memory Care Unit contained a gray plastic grocery bag with a double layer white cake in a plastic container on the top shelf. The container had a best if purchased by, date of 05/18/2026. There was no name on the container or bag. QMA 4 indicated food items brought in by families should be labeled with the resident's name and a date. The snack refrigerator and freezer on Station 4 was observed on 05/20/2026 at 3:08 P.M., with CNA (Certified Nurse Aide) 5 and contained the following: - A gray plastic bag with a plastic container with leftovers was on the second shelf, there was no name on the container or the bag, - In the door was a gray plastic bag with two plastic containers of leftovers, there was no name on the container or the bag, - In the door was an unopened carbonated…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-14 · 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 record review and interview, the facility failed to provide appropriate urinary catheter care for 1 of 3 residents reviewed for urinary catheter care. (Resident C)Findings Include:The clinical record for Resident C was reviewed on 8/14/2025 at 11:30 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 5/22/2025, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension, atrial fibrillation, End-stage renal disease, and Alzheimer's disease. A Progress Note, dated 8/7/2025 at 8:50 A.M., created by Registered Nurse (RN) 2, indicated the Nurse Practitioner (NP) was made aware of Resident C's increase fatigue. New orders were obtained to anchor a urinary catheter and administer a normal saline bolus of 500 cubic centimeter (cc) over two hours and then decrease to 100cc every hour for 48 hours. A Progress Note, dated 8/7/2025 at 2:30 P.M., created by RN 3, indicated Resident C had a 16 French indwelling urinary catheter with a 15 milliliter (ml) balloon. Upon insertion of the urinary catheter there 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-14 · 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

    Based on record review, and interview the facility failed to provide an ordered medication for 1 of 3 resident's reviewed. (Resident B)Findings Include: The clinical record for Resident B was reviewed on 8/14/2025 at 11:18 A.M. The record indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, non-Alzheimer's dementia, atrial fibrillation, and hypertension. A physician's order, dated 6/22/2025, indicated Resident B was to receive Memantine (a cognition medication) 5 milligram (mg), one tablet twice a day.The order was discontinued on 7/7/25 with a note stating, Meds from home no interchange needed. The resident's medication administration record was reviewed. The resident had not received the prescribed Memantine from 7/8/25 through 7/28/25.A Health Status Note, dated 8/08/25 at 3:11 P.M., indicated the family notified the facility of discontinuance of memantine on 7/07/2025. The writer confirmed and notified the Nurse Practitioner (NP). During an interview, on 8/14/2025 at 1:28 P.M., RN 2 indicated that on 7/07/25 she…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-23 · 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 record review and interview, the facility failed to document a fall and start neurological assessments in a timely manner for 1 of 3 residents reviewed for quality of care. (Resident C)Findings include:The clinical record for Resident C was reviewed on 07/22/25 at 9:55 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 05/21/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, stroke, heart failure, hypertension, dementia, anxiety, and depression. The resident used a walker for mobility and required partial to moderate staff assistance for Activities of Daily Living (ADLs). During an interview, on 07/23/25 at 10:53 A.M., the Director of Nursing (DON) indicated she was made aware Resident C had a fall through a text message from RN 2 on 06/09/25 at 11:12 P.M. RN 2 sent a second text message on 06/09/25 at 11:47 P.M. that the resident was having hip pain. She sent a text back advising RN 2 to make the Nurse Practitioner (NP) aware. RN 2 sent a third text message on 06/10/25 at 7:19 A.M., that the NP…

    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
Show the remaining 20 citations
  • Potential for harm · E2025-04-07 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    5. Resident 22's clinical record was reviewed on 04/02/25 at 2:02 P.M. A Quarterly MDS assessment, dated 01/17/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, Parkinson's disease, heart failure, hypertension, anxiety, and dementia. The resident used a wheelchair and required partial to moderate assist from staff for mobility. The resident experienced two or more falls without injury and two or more falls with injury since the last assessment. An Incident Note, dated 01/23/25 at 10:01 A.M., indicated the resident experienced an unwitnessed fall on 01/22/25 at 7:20 A.M. The resident fell from his wheelchair in the dining room. The resident was not injured and denied pain. An intervention to place bright colored tape on the brakes of the wheelchair to remind and encourage the resident to lock brakes on the wheelchair when attempting to stand would be beneficial. The resident's Care Plan for falls included, but was not limited to the following interventions: - An intervention, with a start date of 05/09/23, to use…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-07 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to document an appropriate advance directive for 1 of 16 residents' advanced directives reviewed. (Resident 260) Findings include: The clinical record for Resident 260 was reviewed on [DATE] at 11:20 A.M. An admission Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension, diabetes, and non-Alzheimer's dementia. The resident had a signed Out of Hospital Do Not Resuscitate (DNR) Declaration and Order, dated [DATE], along with a Physician Orders for Scope of Treatment (POST) form that indicated the resident was a DNR signed the same day. A current, open-ended physician's order, dated [DATE], indicated the resident was to receive Cardiopulmonary Resuscitation (CPR). During an interview, on [DATE] at 12:48 P.M., Licensed Practical Nurse (LPN) 2 indicated when a resident admitted to the facility the nurse would complete the POST Forms…

    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 before2025-04-07 · 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 record review and interview, the facility failed to follow MD orders related to cardiac medication administration order parameters for 1 of 16 residents reviewed for Quality of Care. (Resident 27) Findings include: The clinical record for Resident 27 was reviewed on 04/03/25 at 2:55 P.M. A Quarterly Minimum Data Set assessment, dated 12/31/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, anemia, orthostatic hypotension, and disorders of the autonomic nervous system. The resident's current physician's orders included an open-ended order, with a start date of 01/24/25, to administer midodrine (a medication for low blood pressure) 5 mg (milligrams) two times a day for hypotension. The medication was to be held if the resident's systolic (the top number) blood pressure was greater than 140. The resident's Electronic Medication Administration Record (EMAR) for February and March 2025 indicated the resident received the midodrine medication when their blood pressure was assessed and top number was above 140 on 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 before2025-04-07 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to document meal consumption for 1 of 1 residents reviewed for nutrition. (Resident 12) Findings include: 1. The clinical record for Resident 12 was reviewed on 04/03/25 at 11:13 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 12/24/24, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, dementia, hypertension, diabetes, stroke, anxiety, and depression. The resident's meal consumption records lacked documented values on the following dates and times: - On 03/05/25 at breakfast and lunch, - On 03/07/25 at breakfast and lunch, - On 03/09/25 at lunch, - On 03/10/25 at breakfast and lunch - On 03/11/25 at breakfast and lunch, - On 03/12/25 at lunch, - On 03/13/25 at breakfast and lunch, - On 03/15/25 at breakfast and lunch, - On 03/16/25 at breakfast and lunch, - On 03/17/25 at breakfast and lunch, - On 03/18/25 at breakfast and lunch, - On 03/19/25 at breakfast and lunch, - On 03/20/25 at lunch, - On 03/23/25 at breakfast and lunch, - On 03/24/25 at…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-07 · tag F0727 — failed to provide required RN coverage — isolated
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review, the facility failed to provide the required Registered Nurse (RN) on duty for eight consecutive hours a day for 2 of the 7 days reviewed. Findings include: The as worked nursing schedule, from 04/01/25 to 04/06/25, indicated there had not been an RN on duty for eight consecutive hours on Saturday, 04/05/25 and Sunday, 04/06/25. During an interview, on 04/07/25 at 1:42 P.M., the Director of Nursing (DON) indicated RN 3 worked night shift on Saturday 04/05/25 and Sunday 04/06/25. He was the only RN on the schedule for the weekend. His hours were not eight consecutive hours for each day. During an interview, on 04/07/25 at 2:10 P.M., the DON indicated the facility did not have a policy for RN coverage, they followed State and Federal regulations. 3.1-17(b)(3)

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-07 · 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 record review and interview, the facility failed to transcribed medications on admission for 1 of 16 residents reviewed for pharmacy services. (Resident 3) Findings include: The clinical record for Resident 3 was reviewed on 04/02/25 at 1:59 P.M. An Annual Minimum Data Set (MDS) assessment, dated 01/22/25, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, diabetes, anemia, heart failure, hypertension, seizure disorder, non-Alzheimer's dementia, and depression. A Psychiatry Progress Note, dated 01/07/25, indicated the residents Fluoxetine (an antidepressant) medication was to be increased from 60 milligrams (mg) to 80 milligrams once a day, due to the resident having increased behaviors of increased irritability and being easily angered. The resident was admitted to the local hospital on [DATE] and returned to the facility on [DATE]. The hospital discharge instructions, dated [DATE], indicated the resident was to receive Fluoxetine 80…

    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 · Dcited before2025-04-07 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure 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 appropriately store medications for 1 of 2 medication rooms reviewed. (Station 4 Medication Room) Findings include: The Medication Room on Station 4 was observed with Licensed Practical Nurse (LPN) 2 on 04/07/25 at 8:56 A.M. The medication refrigerator contained the following items: - A box that contained an opened vial of TB (Tuberculin) serum. The vial was not labeled with an opened on date. The box indicated the serum was received from the pharmacy on 02/06/25, and - A clear plastic bag that contained two boxes of TB serum. One of the vials had been opened and used. The vial was not labeled with an opened on date. The label on the bag indicated the serum was received from the pharmacy on 02/26/25. During an interview, on 04/07/25 at 8:56 A.M., LPN 2 indicated the TB serum should have been dated when it was opened and first used. There had been 3 or 4 residents admitted to Station 4 since the medication was delivered from the pharmacy. The TB serum package insert was provided by the Director of Nursing…

    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 · D2025-04-07 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to obtain a urinalysis in a timely manner for 1 of 6 residents reviewed for laboratory services. (Resident 27) Findings include: The clinical record for Resident 27 was reviewed on 04/03/25 at 2:55 P.M. A Quarterly Minimum Data Set assessment, dated 12/31/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, anemia, orthostatic hypotension, renal insufficiency, neurogenic bladder, and disorders of the autonomic nervous system. The resident had an indwelling urinary catheter. A Health Status Note, dated 02/18/25 at 6:16 P.M., indicated the resident had a new physician's order to obtain a urinalysis (UA) with Culture and Sensitivity (C&S). A Health Status Note, dated 02/22/25 at 9:48 P.M., indicated the resident had a pending UA at that time. A Health Status Note, dated 02/25/25 at 2:01 A.M., indicated the resident's urine had been collected for a UA. A Health Status Note, dated 03/03/25 at 7:24 P.M., indicated the resident received their first dose of Ceftriaxone (an…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-07 · 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 follow infection control guidelines related to Peripherally Inserted Central Catheter (PICC) lines and indwelling urinary catheters for 3 of 6 residents reviewed for infection control. (Resident 27, 18, and 1) Findings include: 1. Resident 27's clinical record was observed on 04/03/25 at 2:55 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 12/31/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, anemia, orthostatic hypotension, renal insufficiency, neurogenic bladder, and disorders of the autonomic nervous system. A Health Status Note, dated 03/21/25 at 6:31 P.M., indicated a PICC line was placed in the resident's right arm. The resident denied pain or discomfort. The resident's current physician's orders included, but were not limited to the following: - An open-ended order, with a start date of 03/24/25, to change the PICC line dressing every 7 days and as needed, and - An open-ended order, with a start date of 03/24/25, to monitor 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-19 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident received appropriate care and treatment in a timely manner after experiencing an unwitnessed fall for 1 of 3 residents reviewed for falls. (Resident E) Findings include: During an interview on 12/18/24 at 1:20 P.M., Certified Nurse Aide (CNA) 2 indicated Resident E fell on the morning of 12/11/24. She was standing at the nurses' station, and the resident was in his room and his door was open. She saw the resident stand up from his recliner. She told him to, Hold on, and as she rounded the corner of the counter heading to his room he must have fallen because he was on the floor laying on his left side by the time she had gotten to him. Licensed Practical Nurse (LPN) 3 came in, assessed the resident, and then they both assisted him up from the floor and into his bed. The resident walked with assistance to the bed and did not indicate he was in any pain. A short time later, as CNA 2 was providing personal hygiene care, she noticed 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 · D2024-12-19 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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 interview and record review, the facility failed to document and report forward of a resident's fall to ensure a resident received appropriate care and treatment in a timely manner for 1 of 3 residents reviewed for Resident Records. (Resident E) Findings include: During an interview on 12/18/24 at 1:20 P.M., Certified Nurse Aide (CNA) 2 indicated Resident E fell on the morning of 12/11/24. She was standing at the nurses' station, and the resident was in his room and his door was open. She saw the resident stand up from his recliner. She told him to, Hold on, and as she rounded the corner of the counter heading to his room he must have fallen because he was on the floor laying on his left side by the time she had gotten to him. Licensed Practical Nurse (LPN) 3 came in, assessed the resident, and then they both assisted him up from the floor and into his bed. The resident walked with assistance to the bed and did not indicate he was in any pain. A short time later, as CNA 2 was providing personal hygiene…

    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 · D2024-11-01 · 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 record review and interview, the facility failed to ensure an allegation of abuse was reported to the Indiana Department of Health (IDOH) within two hours of the abuse allegation for 1 of 4 residents reviewed for abuse. (Resident F) Findings include: An anonymous interview during the survey process from October 30, 2024 at 9:00 A.M. through November 1, 2024 at 12:30 P.M., Staff Member 50 indicated they had witnessed Staff Member 11 oddly personalize herself with Resident F. They witnessed the resident and Staff Member 11 lying in bed together multiple times. Sometimes Staff Member 11 would be under the covers with the resident. When Staff Member 11 was in the resident's room Resident F would fondle her breasts and grab her butt. Staff Member 11's response was to giggle and never redirected the resident. Over the weekend Staff Member 11 sat with Resident F in his recliner with the resident's hand on her butt. An anonymous telephone interview conducted during the survey process from October 30, 2024 through November 1, 2024 12:30 P.M., Staff Member 32 indicated they had…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-01 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 the Minimum Data Set (MDS) assessments were accurately completed for 1 of 4 residents related to behaviors. (Resident F) Findings include: During an observation and interview on 11/01/24 at 10:29 A.M., Resident F was observed punching the side of his wheelchair. During an interview with the Director Of Nursing (DON) on 11/01/24 9:51 A.M., she indicated Resident F had behaviors of grabbing since the beginning and the interventions were to redirect. A Quarterly MDS assessment, dated 06/06/24, indicated Resident F's cognition was severely impaired. He was dependent on staff for activities of daily living. The Resident had no behaviors documented on Section E Behavior Symptoms of hitting, kicking, pushing, scratching, or sexual acts. The behavior log dated from May 30, 2024 to June 6, 2024, indicated the resident had exhibited grabbing behaviors on the following dates: - 05/30/24, - 05/31/24, - 06/01/24, - 06/02/24, - 06/04/24, and - 06/05/24 A Quarterly MDS assessment, dated 08/30/24, indicated 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-01 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and observation, the facility failed to revise a residents behavior plan of care related to interventions for 1 of 4 residents reviewed for care plan revision. (Resident F) Findings include: The clinical record for Resident F was reviewed on 11/01/24 at 8:16 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 08/30/24, indicated the resident's cognition was severely impaired. The resident's diagnoses include, but were not limited to, aphasia, hypertension, depression, and stroke. A current care plan, with initiated date of 04/18/24, indicated Resident F made sexual gestures towards female staff and a history of inappropriate touching. The interventions included, but were not limited to, dated 4/18/24, if behavior occurs immediately stop care, preserve residents' rights dignity and safety, and then step away. A current care plan, with initiated date of 5/24/24, indicated Resident F had manipulative behaviors of hitting the arm of his wheelchair and grabbed staff during care. The interventions included, but were not limited to, dated 5/24/24,…

    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 · D2024-11-01 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    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 monitor, completely document, and address a residents behaviors related to health services for 1 of 4 residents reviewed. (Resident F) Findings include: During an observation and interview on 11/01/24 at 10:29 A.M., CNA 30 indicated they had just finished providing care for the resident and Resident F was very grabby today. The Resident was observed repeatedly punching the side of his wheelchair. An anonymous interview during the survey process with Staff Member 21 from October 30, 2024 9:00 A.M. through November 1, 2024 12:30 P.M., they indicated that Resident F had full mobility of his right hand, and he grabbed at everyone with it. When staff were changing him he would grab at their breasts or other private areas. If staff told him to stop, he would start digging his fingernails into them. He has dislocated thumbs of staff members before. An anonymous interview during the survey process with Staff Member 38 from October 30, 2024 9:00 A.M. through November 1, 2024 12:30 P.M., they indicated while working…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-30 · 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 follow manufacturer's guidelines related to insulin pen usage (Residents 35), and failed to follow physician's orders related to hold parameters for a blood pressure medication (Resident 52) for 2 of 7 residents reviewed for quality of care. Findings include: 1. Medication administration was observed on 05/29/24 at 9:03 A.M., with RN 3. The RN retrieved an Insulin Aspart pen and a Basalgar insulin pen from a plastic bag and indicated Resident 35 was to receive 15 units of the Aspart (a short-acting insulin) and 30 units of Basalgar (a long-acting insulin). The nurse applied needles to both pens but did not cleanse the rubber seals with an alcohol wipe before attaching the needles. She turned the dials at the end of the pens to the appropriate doses and then dialed up an additional 3 units per pen to prime the pens. The RN held the pens sideways and primed both pens, cleansed the resident's skin and administered the insulin. During an interview following the medication administration, the RN indicated she…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-30 · 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 observation, interview, and record review, the facility failed to provide resident education related to urinary catheter care related to risk of placement for 1 of 2 residents reviewed for urinary catheters. (Resident 29) Findings include: During an observation on 05/29/24 at 12:48 P.M., Resident 29 was self-transferring to their wheelchair in their room. The urinary catheter bag was hanging on the right side of the wheelchair under the arm rest above the resident's waist. During an observation on 05/29/24 at 1:14 P.M., the resident was sitting in her wheelchair with her urinary catheter bag hanging off the right side of the wheelchair under the arm rest above the resident's waist in the main dining room. During an observation 05/29/24 at 3:35 P.M., the resident was in the public bathroom by the main entrance doors, emptying her urinary catheter bag into the toilet while she was sitting in her wheelchair. During an observation on 05/30/24 at 10:08 A.M., the resident was sitting at the nurse's station in their wheelchair with their urinary catheter bag under the right-side…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-30 · 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 follow infection control guidelines related to indwelling urinary catheters for 1 of 2 residents reviewed for urinary catheters. (Resident 51) Findings include: On 05/23/24 at 11:43 A.M., Resident 51 was observed in his wheelchair in the main dining room. The resident's urinary catheter drainage bag was in a dignity pouch. The drainage bag and pouch were hanging from his wheelchair, with the bottom of the pouch resting on the dining room floor. On 05/24/24 at 10:01 A.M., the resident was in his room sitting in a recliner. The resident's catheter drainage bag was hanging from his wheelchair and not in a dignity pouch. The bottom of the residents catheter drainage bag was resting directly on the floor. The resident indicated he had not had the urinary catheter for very long. On 05/28/24 at 10:41 A.M., the resident was in his room in bed. The resident's catheter drainage bag was in a dignity pouch. The bag and pouch were laying in a plastic wash basin on the floor. The resident's record was reviewed on 05/28/24…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-02 · 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

    Based on interview, observation, and record review, the facility failed to assure the appropriate resident received prescribed medications for 1 of 4 residents reviewed for pharmacy services. (Resident B) Findings included: During an interview on 02/02/24 at 10:12 A.M., QMA (Qualified Medication Aide) 3 indicated there had been an incident when a resident received the wrong medications. She had Resident D's medications in a cup and sat them down on her food tray in the dining room of the Dementia Unit. The QMA turned her back to the resident. Usually, the resident took her medications right away. As the QMA was returning to the table with Resident B's medications, Resident D asked where her medications were. The QMA asked Resident D if she had not taken her medications. The QMA took medications to resident B who indicated he had already taken his medications (meaning he had taken Resident D's). Following the incident, the QMA indicated she would stand and wait until residents took all their medications. She had not had an issue before. She would put their medication on their tray…

    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
  • No harm found · C2025-04-07 · tag F0577 — widespread
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure State Survey Results were available to view for 3 of 5 days during the survey. Findings include: During an observation, on 04/02/25 at 3:00 P.M., the survey results were not available to view. There was no posting close to the front entrance indicating where the results were located. During an observation, on 04/03/25 at 11:30 A.M., the survey results were not available to view. There was no posting close to the front entrance indicating where the results were located. During an observation, on 04/03/25 at 12:37 P.M., a sign in the hallway by the therapy department indicated the State Survey results could be found in the file on the wall pocket. The survey results were not in the wall pocket and there was nothing posted close to the front door that indicated where the results were located. During an observation, on 04/04/25 at 9:10 A.M., the survey results were not available to view. There was no posting close to the front entrance indicating where the results were located. During an interview, on 04/04/25 at 12:24…

    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

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
CLAXTON, RYANIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/27/2025
GREENBURG IN OPCO LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2023
FRANKEL, ISRAELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2023
MEAL, KELSEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/08/2024
RADADIYA, PRAGNESHKUMARIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/20/2025

CMS files one row per role, so the 11 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

$5.6M
Net patient revenuemost recent cost report
-3.3%
Operating marginrevenue minus expenses
$941K
Related-party expense16% of expenses
Who pays — share of resident-days
Medicaid 51%Medicare 6%Other / private 43%

This home reported $941K paid to related parties — landlords or management companies under common ownership — equal to about 16% 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

$304per resident / day
operating cost
$9,254per month
≈ monthly operating cost
$295per 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 155210. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-20, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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