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Envive Of Hartford City

715 N Mill St, Hartford City, IN 47348 · For profit - Corporation · 78 certified beds · (765) 348-2273 Medicare & Medicaid certified

Call the home — (765) 348-2273 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 Nov 2025Behavioral-health or dementia-care citations — no harm found (F0744, F0758)
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (20% vs 45% nationally) — better care continuity
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
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • about 24% of its spending goes to commonly-owned related companies

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

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

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

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
124 N Jefferson St · (765) 347-8279 · Call to confirm hours
Pharmacy
1700 N Walnut St · (765) 348-4134 · Call to confirm hours
Grocery
1711 N Walnut St · (765) 348-3399 · Call to confirm hours
Park
701 E Kickapoo St · Typically dawn to dusk
Place of worship

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 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 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 increased12.1%11.0%15.4%better
Long-stay residents who lose too much weight10.8%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.7%0.4%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.9%1.1%2.0%typical
Long-stay residents with depressive symptoms59.3%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 injury3.9%3.9%3.3%worse
Long-stay residents whose ability to walk worsened11.9%11.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication15.1%23.5%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%95.4%95.3%typical
Long-stay residents with pressure ulcers6.1%3.6%4.7%worse
Long-stay residents with worsening bladder/bowel control28.7%23.3%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table28.4%13.6%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine26.1%79.0%79.4%worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

52.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 28 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

52.8%U.S. median 51.5%
Got home and stayed home
10.7%U.S. median 10.7%
Went back to hospital
not reportedno hours filed
Therapy hours / resident / day

Therapy staffing: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

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 SNF52.8%CMS range 37.5–63.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.7%CMS range 7.5–15.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care 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 staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.1%CMS range 3.9–11.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.971.02Oct 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

1.00
RN hours/ resident / day
0.23
LPN hours/ resident / day
2.06
Aide hours/ resident / day
3.29
Total nurse hours/ resident / day
0.87
RN hoursweekends
20.0%
Total nursing turnover
0.0%
RN turnover

How full it usually is: this home is certified for 78 beds and averages 34.9 residents a day — about 45% occupied, or roughly 43 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.29 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 1.00 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.06 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 3.09 hrs/resident/day on weekends vs 3.38 on weekdays — 8% thinner on weekends. RN hours go from 1.05 to 0.87 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 20% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

4
deficiencies at the latest standard inspection (2025-09-26)
3
at the previous standard inspection (2024-11-08)

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.

22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.

  • Potential for harm · Dcited before2025-11-07 · 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 report an allegation of abuse to the State Agency within the required time frame. (Resident B) Findings include A facility reported incident, dated 10/27/25 at 4:19 p.m., submitted to the Indiana Department of Health indicated an incident occurred on 10/27/25 at 3:01 p.m. The reported incident indicated the following: On 10/27/25 Resident B reported to the Administrator that CNAs yelled at her on 10/26/25. On 10/27/25 an investigation was initiated, and the CNAs were suspended pending the investigation outcome. Review of the facility's abuse investigation file, provided on 11/6/25 at 11:49 a.m., included the following: RN 9's statement indicated Resident B's representative approached the nurses station on 10/26/25 at approximately 1:00 p.m. and asked to talk to someone about a concern she had regarding the resident. Resident B had reported to her that Resident B had overheard, at lunch, the CNAs say from around a corner that she was old enough and should not be peeing herself, and that they were not going to continue 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-07 · 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 record review and interview, the facility failed to conduct a thorough investigation of an allegation of abuse and failed to implement immediate interventions to prevent potential abuse while the investigation was in progress. (Resident B) Findings include: A facility reported incident, dated 10/27/25 at 4:19 p.m., submitted to the Indiana Department of Health indicated an incident occurred on 10/27/25 at 3:01 p.m. The reported incident indicated the following: On 10/27/25 Resident B reported to the Administrator that CNAs yelled at her on 10/26/25. On 10/27/25 an investigation was initiated, and the CNAs were suspended pending the investigation outcome. CNA 3 and CNA 5 were the CNAs mentioned in the report. The clinical record for Resident B was reviewed on 11/6/25 at 10:30 a.m. Diagnoses included fracture of lower end of left femur, chronic kidney disease, stage 4, type 2 diabetes mellitus with diabetic polyneuropathy, morbid obesity due to excess calories, anxiety disorder, and muscle weakness. Current orders included torsemide (diuretic) 20 mg daily and resident uses a…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-26 · 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 interview, observation, and record review, the facility failed to protect a resident's dignity by failing to provide necessary assistive mechanical lift slings for the transfer process resulting in a resident having to remain in bed despite her preferences for daily activities for 1 of 3 residents reviewed for dignity. (Resident 26)Finding includes: During an interview, on 9/22/25 at 10:34 a.m., Resident 26 indicated she required a mechanical lift for transferring from bed to her wheelchair and back to the bed. She was informed by facility staff there was a limited supply of mechanical lift slings, and she had to stay in bed over the previous weekend due to a mechanical lift sling not being available. She had soiled her sling due to incontinence and then had to wait for two days for the sling to be washed, air dried, and returned to the floor. Resident 26's clinical record was reviewed on 9/25/25 at 4:02 p.m. Diagnoses included muscle wasting and atrophy (shrink), fracture of the lower end of the femur (thigh bone that extends from hip to knee), morbid obesity, muscle…

    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 · D2025-09-26 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    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 ordered adaptive equipment for eating was provided for 1 of 3 residents reviewed for activities of daily living (ADLs) (Resident 29). Finding includes: During an observation, on 9/22/25 at 11:40 a.m., Resident 29 was served lunch. His meal was served on a regular plate, regular bowl, and regular utensils. No adaptive utensils, plateware, or cups were observed in the dining room. During an observation, on 9/23/25 at 11:44 a.m., Resident 29 used regular utensils, cups, and plates during lunch. Resident 29's clinical record was reviewed on 9/24/25 at 3:04 p.m. Diagnoses included unspecified intellectual disabilities, vascular dementia, muscle weakness (generalized), and dysphagia (difficulty/discomfort swallowing) oropharyngeal phase. Current orders included resident to use built up handled utensils, one handled cup with spout, scoop bowl, and plate with suction base at all meals (9/27/24). An annual Minimum Data Set (MDS) assessment, dated 7/11/25, indicated the resident was severely cognitively…

    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 · D2025-09-26 · 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 interview, observation, and record review, the facility failed to provide transfer assistance to a dependent resident for 1 of 3 residents reviewed for activities of daily living (ADLs). (Resident 26)Finding includes:During an interview, on 9/22/25 at 10:34 a.m., Resident 26 indicated she required a mechanical lift for transferring from bed to her wheelchair and back to the bed. She was informed by facility staff there was a limited supply of mechanical lift slings, and she had to stay in bed over the previous weekend due to a mechanical lift sling not being available. She had soiled her sling due to incontinence and then had to wait for two days for the sling to be washed, air dried, and returned to the floor. Resident 26's clinical record was reviewed on 9/25/25 at 4:02 p.m. Diagnoses included muscle wasting and atrophy (shrink), fracture of the lower end of the femur (thigh bone that extends from hip to knee), morbid obesity, muscle weakness, and anxiety.A 9/2/25, admission, Minimum Data Set (MDS) assessment indicated Resident 26' was cognitively intact. She 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 · D2025-09-26 · 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 observation, record review, and interview, the facility failed to ensure the physician ordered diet was followed for 1 of 3 residents reviewed for nutrition (Resident 16). Finding includes:Resident 16's clinical record was reviewed on 9/24/25 at 3:47 p.m. Diagnoses included type 2 diabetes mellitus without complications, vitamin B12 deficiency anemia, and dementia.Current orders included regular diet with mechanical soft texture, no mashed potatoes, straws with liquids and given on right side of mouth, small sips (5/2/25), sitagliptin phosphate (for diabetes) 50 mg daily (9/24/25), and insulin glargine 100 units/mL - inject 15 units twice a day (5/10/25). A quarterly Minimum Data Set (MDS) assessment, dated 7/21/25, indicated the resident was severely cognitively impaired. He required supervision and cueing with eating. A current nutritional care plan (revised on 5/21/25) indicated the resident was at risk for malnutrition related to chronic disease, a body mass index greater than 25, and altered carbohydrate metabolism from diabetes. Interventions included provide 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 · F2025-08-06 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure carpeting in resident rooms, hallways and common areas were clean and free from stains for 2 of 2 units in the facility (100 hall and 200 hall). This deficient practice had the potential to impact 25 of 25 residents who resided in the facility. Findings include:Confidential interviews were conducted during the survey. During a confidential interview, it was indicated the hallways had spots or stains. The facility said they would have the carpet cleaned. It was at least five months since they shampooed it. It needed a good scrub. During a confidential interview, it was indicated the facility shampooed the carpet once in a while, but not often.During a confidential interview, it was indicated there had been spots on hallway carpets for quite a while.During a confidential interview, it was indicated there was heavy staining on the carpet in empty resident rooms.During a confidential interview, it was indicated the facility did not…

    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 before2025-03-13 · 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 ensure resident medications were properly labeled and disposed of for 1 of 3 medication carts observed. (200 Front Hall Cart) Finding includes: During an observation, on 3/13/25 beginning at 11:04 a.m., the top drawer in the left section of the 200 Front Hall Medication Cart contained an uncovered paper medication cup containing a green capsule, two cream-colored capsules, two round white tablets, and one oblong oval shaped white tablet. The paper cup had Resident N's last name and the words evening meds written in pen on it. During an interview, at the same time of the observation above, LPN 3 indicated she had not noticed the paper cup of medications in the cart when she passed medications earlier. Resident N had probably refused the medications, and the evening shift nurse had forgotten to destroy them. When a resident refused his/her medication, the medication should be destroyed right away. During an interview, on 3/13/25 at 11:06 a.m., the Director of Nursing indicated medications should be destroyed…

    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 · D2024-11-08 · 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

    A. Based on observation, interview, and record review the facility failed to follow physician's orders for 1 of 16 residents reviewed for resident choices. (Resident C) B. Based on interview and record review, the facility failed to follow up on reported resident's concerns for 1 of 16 residents reviewed for resident choices. (Resident B) Findings include: A. During an interview on 11/1/24 at 1:51 p.m., Resident C's representative indicated the resident had problems with swelling in his lower extremities. The resident had requested compression wraps for his bilateral lower legs some time back, but the facility had not provided the compression wraps. The resident's representative indicated he had asked the nurse again on 11/1/24 for compression wraps for the resident's bilateral lower legs to help with the ongoing swelling in the resident's lower legs and feet. During an observation at the time of interview, the resident's bilateral legs and feet were elevated in his recliner, moderately swollen, and without compression wraps. During an observation on 11/6/24 at 4:20 p.m., 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 · D2024-11-08 · 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 pharmacy recommendations were reviewed and addressed in a timely manner for 2 of 5 residents reviewed for unnecessary medications (Resident 16 and Resident 18). Findings include: 1. Resident 16's clinical record was reviewed on 11/7/24 at 11:52 a.m. Diagnoses included aphasia following cerebral infarction, depression, disorientation, and anxiety disorder. Physician's orders included lorazepam (antianxiety) 0.5 mg (milligrams) two tablets every 4 hours as needed (PRN) for anxiety/agitation (started 10/27/24) and lorazepam 0.5 mg every 6 hours PRN anxiety/agitation (started 8/5/24 and discontinued 10/27/24). A significant change Minimum Data Set (MDS) assessment, dated 8/28/24, indicated the resident was severely cognitively impaired. A medication administration record for August 2024 indicated the resident was given lorazepam 0.5 mg on 8/5/24 at 5:04 p.m. and 11:05 p.m., 8/7/24 at 11:24 a.m., and 8/12/24 at 9:03 p.m. A medication regimen review, completed on 8/19/24, indicated lorazepam 0.5 mg give every 6 hours PRN…

    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 12 citations
  • Potential for harm · Dcited before2024-11-08 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of an as needed (PRN) psychoactive medication for 2 of 5 residents reviewed for unnecessary medications. (Resident 16 and Resident 28) Findings include: 1. During an observation, on 11/4/24 at 9:20 a.m., Resident 16 rested in bed with his eyes closed. On 11/6/24 at 3:59 p.m., the resident rested in bed in bed with his eyes closed and leaned right. On 11/7/24 at 12:43 p.m., the resident rested in bed with his eyes gazing at the television. Resident 16's clinical record was reviewed on 11/7/24 at 11:52 a.m. Diagnoses included aphasia following cerebral infarction, depression, disorientation, and anxiety disorder. Physician's orders included lorazepam (antianxiety) 0.5 mg (milligrams) two tablets every 4 hours PRN for anxiety/agitation (started 10/27/24), lorazepam 0.5 mg every 6 hours PRN anxiety/agitation (started 8/5/24 and discontinued 10/27/24), and duloxetine (antidepressant) delayed release 90 mg daily (started 10/22/24).…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-08 · 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 utilize infection prevention and control procedures during insulin administration for 2 of 4 residents reviewed for medication administration. (Residents 16 and 7) Findings include: 1. During a random medication administration observation on 11/6/24 at 10:56 a.m., RN 5 removed Resident 16's insulin aspart Flexpen 100 units/milliliter(mL) from the compartment in the top drawer of the medication cart where the insulin pens for the residents on the 200 unit were stored. She removed the unsealed pen cap, did not cleanse the rubber stopper of the multi-dose pen, and attached the pen needle to the insulin pen. The pen was primed and dialed to 11 units for scheduled and sliding scale insulin. The skin was cleansed with an alcohol pad, and the insulin was administered subcutaneously in the resident's right lower abdomen. Resident 16's clinical record was reviewed on 11/8/24 at 12:35 p.m. Diagnoses included, type 2 diabetes mellitus with diabetic neuropathy. Current physician's orders, dated 5/8/24, included insulin…

    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 before2024-06-17 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an abuse allegation was reported to the Indiana Department of Health for 1 of 4 residents reviewed for abuse. (Resident D and Resident B) Findings include: During an interview with Resident D, on 6/14/24 at 1:07 p.m., she indicated when she was in her previous room, Resident B had pushed her into her room from behind and told her to stay in her room, and she didn't need to be coming out of her room. Resident D reported this to the Administrator and the Social Service Director and completed a grievance form. Resident D's clinical record was reviewed on 6/14/24 at 12:50 p.m. A significant change Minimum Data Set (MDS) assessment indicated she was cognitively intact. She had a care plan for making false statements/accusations towards staff and other residents, i.e. making statements that she was hit or pushed by another resident when it was impossible for that to have happened (Revised 4/23/24). Her interventions included allow her to vent feelings…

    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 · F2023-12-19 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) worked 8 consecutive hours in the facility on any given day. This had the potential to affect 30 of 30 residents who resided in the facility. Findings include: A Payroll Based Journal (PBJ) report, compiled on 12/7/23 for Fiscal Year 2023's 3rd quarter (April 1 - June 30), indicated four or more days within the quarter with no RN hours. The report indicated the dates without RN coverage included April 1, April 2, April 15, April 29, May 13, and May 14. A review of the facility's Daily Nursing Assignment Sheets indicated the following: On April 1, there had not been an RN for eight consecutive hours at the facility. On April 2, there had not been an RN for eight consecutive hours at the facility. On April 15, there had not been an RN for eight consecutive hours at the facility. On April 29, the DON was included as having been at the facility for eight consecutive hours for RN coverage. On May 13, there had not been an RN for eight consecutive hours at the facility. On May 14, there had not…

    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 · F2023-12-19 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the appropriate storage of refrigerated foods by the use of a refrigerator unable to maintain refrigeration at safe levels. This deficiency had the potential to affect 30 of 30 residents residing in the facility who received meals from the kitchen. Finding includes: During an observation, on 12/13/23 at 10:07 a.m., the kitchen refrigerator temperature was 46 degrees Fahrenheit (F). The refrigerator contained various items including cheese and other dairy products. The Dietary Manager, at the same time, indicated the staff had been in and out of the refrigerator recently. She thought this was why the refrigerator temperature was reading 46 degrees F. Review of a facility Resource: Refrigerator/Freezer Temperature Log, document, provided by the Administrator on 12/13/23 at 11:02 a.m., indicated the refrigerator temperatures for December 2023 were as follows: 12/1/23 morning 41 degrees, evening 46 degrees 12/2/23 morning 44 degrees,…

    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 · D2023-12-19 · tag F0576 — isolated
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure residents' right to receive mail on Saturdays was maintained for 9 of 9 residents interviewed during a resident council meeting. Findings include: During a resident council interview, on 12/15/23 at 2:00 p.m., the residents present indicated mail was not delivered on Saturdays. During an interview, on 12/15/23 at 3:13 p.m., the Administrator indicated the mail was sorted and delivered to residents Monday through Friday, but they did not pass mail on Saturdays. Review of an undated, current facility policy, titled INDIANA RESIDENT RIGHTS & FACILITY RESPONSIBILITIES, provided by the DON on 12/19/23 at 3:58 p.m., indicated it is the facility's policy to abide by all resident rights, and to communicate these rights to residents and their designated representatives in a language that they can understand .(s) The resident has the right to privacy in written communications, including the right to: (1) send and promptly receive mail that is unopened. 3.1-3(s)(1)

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-19 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    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 with PTSD (Post Traumatic Stress Disorder) received care to mitigate triggers that may cause re-traumatization for 1 of 1 residents reviewed for trauma informed care (Resident 26). Findings include: During an observation, on 12/15/23 at 10:34 a.m., Resident 26 was outside for a smoke break with a staff member and four other residents. Her clinical record was reviewed on 12/15/23 at 11:00 a.m. Diagnoses included PTSD. Current physician orders included Seroquel (anti-psychotic) 25 mg, give two tablets (50 mg) at bedtime for PTSD, ordered 10/6/23. A 10/17/23 admission MDS (Minimum Data Set) assessment indicated she was cognitively intact. She had no mood or behaviors. She received an anti-psychotic medication on a routine basis. A current care plan, dated 10/19/23, indicated she used anti-psychotic medications related to traumatic stress disorder. The goal, with a target date of 1/23/23, indicated she would remain free of psychotropic drug related complications, including movement disorder,…

    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 before2023-12-19 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident received individualized, non-pharmacological interventions for dementia-type behaviors before increasing psychoactive medications for 2 of 5 residents reviewed for dementia care (Resident 18 and 25). Finding includes: 1. During an observation, on 12/15/23 at 9:53 a.m., Resident 18 was conversing with her roommate in her room. During an observation, on 12/19/23 at 10:34 a.m., Resident 18 was sitting in her wheelchair in her room crocheting. Resident 18's clinical record was reviewed on 12/15/23 at 9:15 a.m. She was admitted on [DATE]. Her diagnoses included anxiety disorder, unspecified, unspecified dementia, unspecified severity with anxiety, unspecified dementia, unspecified severity, with mood disturbance, major depressive disorder, single episode, moderate, and unspecified dementia, unspecified severity, with agitation. Her physician's orders included donepezil (for Alzheimer's disease)10 mg at bedtime (12/5/22),…

    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 before2023-12-19 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure non-pharmacological interventions were employed prior to increasing an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications (Resident 18). Finding includes: During an observation, on 12/15/23 at 9:53 a.m., Resident 18 was conversing with her roommate in her room. During an observation, on 12/19/23 at 10:34 a.m., Resident 18 was sitting in her wheelchair in her room crocheting. Resident 18's clinical record was reviewed on 12/15/23 at 9:15 a.m. She was admitted on [DATE]. Her diagnoses included anxiety disorder, unspecified, unspecified dementia, unspecified severity with anxiety, unspecified dementia, unspecified severity, with mood disturbance, major depressive disorder, single episode, moderate, and unspecified dementia, unspecified severity, with agitation. Her physician's orders included donepezil (for Alzheimer's disease)10 mg at bedtime (12/5/22), quetiapine fumarate (antipsychotic) 50 mg daily…

    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 before2023-12-19 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY A. Based on observation, interview, and record review, the facility failed to ensure biologicals requiring refrigeration were monitored per CDC guidelines for 1 of 1 refrigerators reviewed for medication/biological storage. B. Based on observation, interview, and record review, the facility failed to ensure residents' medications were properly disposed of or sent back to the pharmacy for credit for 1 of 1 medication storage rooms observed. Findings include: A. During an observation of the medication storage room beginning on [DATE] at 8:49 a.m., with RN 51, the medication refrigerator contained 10 vials/doses of influenza vaccines and had a standard thermometer. The refrigerator log indicated the refrigerator temperature was monitored daily. A facility document, provided by the DON on [DATE] at 10:08 a.m., titled Daily Freezer/Refrigerator Temperature Log, indicated the location was the medication room for [DATE]. Temperatures for the refrigerator were taken daily. During an interview, on [DATE] at 10:08 a.m.,…

    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 · D2023-12-19 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    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 residents were offered the latest and recommended COVID-19 vaccine for 4 of 5 residents reviewed for COVID-19 vaccinations (Residents 12, 25, 23, and 18). Findings include: 1. Resident 12's clinical record was reviewed on 2/18/23 at 9:42 a.m. Diagnoses included, type 2 diabetes mellitus and malignant neoplasm of unspecified site of left female breast. A COVID-19 Resident Vaccine Education form, signed by the resident and dated 8/8/22, indicated she requested the facility ensured she was vaccinated as soon as available. A review of her immunization status indicated her last COVID-19 vaccine had been administered on 12/6/22. Her clinical record lacked information that she had been offered the latest and recommended vaccine for COVID-19. 2. Resident 25's clinical record was reviewed on 12/15/23 at 9:36 a.m. Diagnoses included, type 2 diabetes mellitus and atherosclerotic heart disease. An informed consent of COVID-19 vaccine was signed by the resident and dated 9/14/23. A review of her immunization history status…

    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 before2023-11-03 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement individualized interventions for a cognitively impaired resident who displayed sexual behaviors for 1 of 3 residents reviewed for behaviors (Resident C). Findings include: Resident C's clinical record was reviewed on 11/3/23 at 10:16 a.m. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, wandering in diseases classified elsewhere and unspecified dementia, moderate, with other behavioral disturbance. An order initiated on 11/3/23 at 10:03 a.m. indicated to monitor the resident for behaviors related to being sexual in nature: roaming/wandering in other resident's rooms, inappropriate gestures, and seeking male residents. Notify the RN immediately. Redirect her immediately and document the outcomes every two hours. A 10/24/23, quarterly, Minimum Data Set (MDS) assessment indicated she was severely cognitively impaired and had delusions (misconceptions or beliefs that are…

    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

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to ENVIVE HEALTHCARE — 12 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 52.2+0.8 vs chain
Health inspection 3 of 52.3+0.7 vs chain
Staffing 3 of 51.8+1.2 vs chain
Quality measures 3 of 53.8-0.8 vs chain
The other 11 homes this chain runs (chain average 2.2★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
BRIDGEWATER PROPERTY HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 01/01/2022
ENVIVE NURSING HOLDINGS, LLCOrganizationINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2022
NBH BANKOrganization5% OR GREATER MORTGAGE INTERESTsince 01/01/2022
BORNE-BAUMAN, CANDICEIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2022
FLUECKIGER, RUSSELLIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2022
LEHMAN, SCOTTIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2022
MACKLIN, LARRYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2022
MCINTIRE, DAVIDIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2022
LT CARE ACQUISITION CORPOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2022
ANDERSON, ROBERTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
JACKMAN, SARAHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/23/2023
SMITH, SCOTTIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2022
SPRUNGER, KYLEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2022
WHEELER, DANEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2022
BLUE MANAGEMENT SERVICES LLCOrganizationADP OF THE SNFsince 01/01/2024
ENVIVE HEALTHCARE LLCOrganizationADP OF THE SNFsince 01/01/2022
FIRST BANK OF BERNEOrganizationADP OF THE SNFsince 01/01/2022

CMS files one row per role, so the 28 rows in the source record cover these 17 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.

7 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.

$4.9M
Net patient revenuemost recent cost report
+4.5%
Operating marginrevenue minus expenses
$1.1M
Related-party expense24% of expenses
Who pays — share of resident-days
Medicaid 73%Medicare 7%Other / private 20%

About 73% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 24% 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

$406per resident / day
operating cost
$12,342per month
≈ monthly operating cost
$425per 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 155699. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-26, 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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