Arlington Place Health Campus
1635 N Arlington Ave, Indianapolis, IN 46218 · For profit - Partnership · 84 certified beds · (317) 353-6000 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 4.0% | 11.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.8% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 1.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 4.7% | 25.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.1% | 3.9% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 9.3% | 11.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 6.1% | 23.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 87.2% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.4% | 3.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 31.3% | 23.3% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.1% | 13.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.4% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 71.2% | 79.0% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 19.3% | 22.2% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 7.5% | 10.8% | 12.0% | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
60.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 170 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 57.4% 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 61 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 0.53 therapist hours per resident per day in 2026Q1 — more than 83% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 16% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 60.4%CMS range 52.6–66.9 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 13.2%CMS range 10.4–16.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 57.4% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 54.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 59.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.6% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 94.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.0%CMS range 4.1–11.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.15 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 84 beds and averages 67.5 residents a day — about 80% occupied, or roughly 16 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.74 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 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 3.27 hrs/resident/day on weekends vs 3.93 on weekdays — 17% thinner on weekends. RN hours go from 0.51 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 48% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
21 citations, most serious first. The 10 most serious are shown; the remaining 11 are one tap away and print in full.
- Potential for harm · E2026-05-29 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure food temperatures were at an appetizing temperature and kept at safe holding temperatures. This had the potential to affect 70 of 70 residents that eat the food prepared and served from the kitchen.Findings include:An interview was conducted with Resident D on 5/28/26 at 10:29 a.m. She indicated breakfast, lunch and dinner meals were always served cold.An observation was made of the main kitchen with the DM 11 on 5/28/26 at 12:26 p.m., Dietary Manager (DM) 11 utilizing a thermometer had taken the food temperatures of the prepared food to be served. The smoked sausage had tempted 123 degrees Fahrenheit. DM 11 indicated the smoked sausage needed to be reheated. He preferred all food to be held at 150 degrees Fahrenheit, but the regulation stated food temperatures were to be held at 135 degrees Fahrenheit.During a dining observation on 5/28/26 at 11:57 a.m., Residents' N, O, P were sitting in the dining room waiting for the lunch meal. They indicated the food that was supposed to be hot, was served cold 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.
- Potential for harm · D2026-05-29 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 timely complete self-medication assessments for a resident who had medication at bedside and a resident that self administered her insulin medications 2 of 3 residents medication administration. (Resident F and Resident D) Findings include: 1. The clinical record for Resident F was reviewed on 5/28/26 at 11:00 a.m. The resident's diagnosis included, but was not limited to, depression (serious mood disorder). A Quarterly Minimum Data Set (MDS) Assessment, completed 5/7/26, indicated the resident was moderately cognitively impaired. A care plan, last reviewed 5/20/26, indicated Resident F presented with a diagnosis of depression. The goal was for the resident to remain free of the symptoms of depression. The interventions included to administer medications as ordered by the physician. On 5/28/26 at 11:58 a.m., Resident F was observed in his room, sitting in his bed. The bedside table was next to the bed. A medication cup containing 4 pills was observed on the bedside table. Resident F indicated the nurse 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.
- Potential for harm · D2025-12-08 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure the resident representative for a cognitively impaired resident was informed in advance of the risks and benefits of medications for 1 of 5 residents reviewed for informed consent. (Resident 3)Findings include:The clinical record for Resident 3 was reviewed on 12/4/25 at 10:27 a.m. The diagnoses included, but were not limited to, dementia, chronic kidney disease, and severe protein-calorie malnutrition.A Minimum Data Set (MDS) assessment, dated 10/10/25, indicated the resident was severely impaired cognitively.A physician's order, dated 10/4/25 and discontinued 10/8/25, indicated to administer olanzapine (an antipsychotic medication) 2.5 milligrams twice per day.A physician's order, dated 10/7/25, indicated to administer Trazodone (an antidepressant medication which could be used as an off-label treatment for insomnia) 25 milligrams at bedtime for insomnia.A facility psychotropic medication informed consent observation, dated 10/8/25, indicated Resident 3 was educated on the risks, benefits, alternative treatment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-08 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure the resident representative for a cognitively impaired resident was notified of a significant weight loss for 1 of 3 residents reviewed for notification of change. (Resident 3)Findings include:The clinical record for Resident 3 was reviewed on 12/4/25 at 10:27 a.m. The diagnoses included, but were not limited to, dementia, chronic kidney disease, and severe protein-calorie malnutrition.A Minimum Data Set (MDS) assessment, dated 10/10/25, indicated Resident 3 was severely impaired cognitively.A facility weight log indicated the following:On 10/4/25, the resident weighed 149 pounds on admission.On 11/14/25, the resident weighed 131.8 pounds.On 11/18/25, the resident weighed 130.3 pounds.Resident 3 had a significant weight loss of 11% from 10/4/25 to 11/14/25.There was no documentation in the clinical record to indicate the resident's representative was notified of the significant weight loss.During an interview, on 12/5/25 at 11:25 a.m., the Director of Nursing (DON) indicated Resident 3 had impaired cognition and the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-08 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a bed hold policy was provided to the resident and resident's representative at the time of discharge for 1 of 2 resident reviewed for hospitalization. (Resident 81)Findings include:The clinical record for Resident 81 was reviewed on 12/3/25 at 10:25 a.m. The diagnoses included, but were not limited to, hyperlipidemia, obesity, and acute respiratory failure.A nursing progress note, dated 9/18/25 at 12:35 p.m., indicated Resident 81 was found unresponsive and the staff called 911. The resident was transported to the hospital.There was no documentation the bed hold policy was provided to Resident 81 or Resident 81's representative.A clinical discharge observation form, completed on 9/30/25, did not indicate whether the bed hold policy was provided to the resident and the resident's representative.During an interview, on 12/8/25 at 9:48 a.m., Clinical Support 1 indicated staff should provide the bed hold policy to the resident and resident's representative at the time of discharge.A current facility policy, titled Bed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-08 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed after the addition of mental health diagnoses and psychotropic medications for 2 of 4 residents reviewed for PASARR. (Resident 7 and 11)Findings include:1. The clinical record for Resident 7 was reviewed on 12/3/25 at 11:25 a.m. The diagnoses included, but were not limited to, hypertensive chronic kidney disease, atrial fibrillation, a wedge compression fracture of the second lumbar vertebra, major depressive disorder, chronic obstructive pulmonary disease, and dementia without behavioral disturbance. A PASARR level I screening, dated 5/9/24, indicated Resident 7 was not prescribed any mental health medications and did not have any mental health or dementia diagnoses. A physician's order, dated 8/2/24 and discontinued 9/23/24, indicated to administer escitalopram oxalate (an antidepressant medication) 5 milligrams (mg) once a day for depression. On 9/23/24, the escitalopram oxalate order was changed to 10 mg at bedtime for depression. A physician's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-08 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure medication carts were free of loose pills and debris, narcotic medications with compromised packaging were destroyed, as needed (PRN) controlled drug use records contained documented of approval by a licensed nurse prior to administration and a pharmacy label for a narcotic medication matched the physician's order for 3 of 4 medication carts reviewed for medication storage and labeling. (100-hall cart 1, 100-hall cart 2 and 200-hall cart 2)Findings include:1. The 100-hall medication cart one (1) was observed on 12/4/25 at 9:12 a.m., and had the following:a. Drawer 2, contained two (2) loose pills and powdered debris collected in the bottom of the drawer against the back wall.b. Drawer 6, the narcotic box, contained a narcotic pill pack of oxycodone 5 milligram (mg) 1/2 tablets. The medication card had not been used for administration and contained 30, 1/2 tablets. Pocket 12 was observed to be compromised and was secured closed with a piece of clear tape; the 1/2 tablet was present in the package.c.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-08 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure enhanced barrier precaution signs were posted for residents who required enhanced barrier precaution isolation for 3 of 8 residents reviewed for infection control. (Resident 5, 86 and 87)Findings include: 1. During an observation, on 12/1/25 at 10:18 a.m., Resident 5 had a wound vacuum (a device used to speed up closure by optimizing the wound bed for healing). Resident 5 did not have an enhanced barrier precaution sign posted in or on the outside of the room.During an observation, on 12/1/25 at 11:16 a.m., Resident 5 did not have an enhanced barrier precaution sign posted in or on the outside of the room.During an observation, on 12/1/25 at 12:02 p.m., Resident 5 did not have an enhanced barrier precaution sign posted in or on the outside of the room.During an observation, on 12/1/25 at 2:20 p.m., Resident 5 did not have an enhanced barrier precaution sign posted in or on the outside of the room.The clinical record for Resident 5 was reviewed on 12/4/25 at 2:44 p.m. The diagnoses included, but were 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.
- Potential for harm · D2025-12-08 · tag F0887 — isolatedEducate 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 interview and record review, the facility failed to ensure consents were documented accurately prior to administering a Covid vaccine for 1 of 5 residents reviewed for immunizations. (Resident 51)Findings include: The clinical record for Resident 51 was reviewed on 12/4/25 at 2:15 p.m. The diagnoses included, but were not limited to, acute cystitis without hematuria, anoxic brain damage, elevated white blood cell count, pulmonary fibrosis, dementia, type 2 diabetes mellitus with hyperglycemia, diabetic chronic kidney disease, and aphasia.A Brief Interview for Mental Status (BIMS) assessment, dated 11/6/25, indicated Resident 51 had severe cognitive impairment.A COVID vaccination consent form, dated 1/11/24 at 4:20 p.m., indicated Resident 51's representative refused the COVID vaccination.A COVID vaccination consent form, dated 11/5/25, indicated Resident 51's representative had not signed the consent form for Resident 51 to receive the vaccine. It indicated the Moderna COVID vaccination was given on 11/7/25, in the left arm.A physician's order, dated 11/7/25, indicated the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-10-21 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure beard coverings were worn by the dietary staff with facial hair. This has a potential to affect 42 of 42 residents that receive food prepared in the kitchen. Findings include: An observation was made of the Kitchen with the Director of Food Services on 10/15/24 at 11:44 a.m. During the tour, [NAME] 5 was observed at the food preparation area preparing the lunch meal. [NAME] 5 had facial hair on his lip and chin with no beard covering. An interview was conducted with the Director of Food Services on 10/15/24 at 11:55 a.m. He indicated [NAME] 5 should be wearing a beard covering. A [NAME] and Mustache policy was provided by the Administrator on 10/17/24 at 11:30 a.m. It indicated, .Policy. [NAME] and mustache hair must be covered while in kitchen food product areas. Facial hair restraints are required in any production area. Purpose. Beards and mustache must be covered while in kitchen food product areas. Facial hair restraints are required in any food production area. Facial hair is not exempt from 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.
Show the remaining 11 citations
- Potential for harm · D2024-10-21 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to timely inform a resident and the State Ombudsman Agency of a facility-initiated discharge due to payment coverage, that was initiated following a resident being discharged to an acute care hospital for a medical change of condition, for 1 of 4 residents reviewed for transfer and discharge rights (Resident C). Findings include: The clinical record for Resident C was reviewed on 10/16/24 at 3:05 p.m. The diagnoses included, but were not limited to, pressure ulcer of left and right buttocks. He was discharged to an acute care hospital due to a change of condition on 2/8/24. A Social Services Comprehensive Note, dated 12/22/23, indicated Resident C anticipated remaining in the facility long-term. A nursing progress note, dated 2/8/24 at 4:30 p.m., indicated Resident C remained hypotensive (low blood pressure) and his temperature had decreased. He was showing signs and symptoms of sepsis. Emergency Medical Services were called. A nursing progress note, dated 2/8/24 at 5:18 p.m., indicated Emergency Medical Services had arrived…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-21 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately monitor urinary output and to monitor for symptoms of urinary tract infections for residents with urinary catheters for 2 of 3 residents reviewed for urinary catheters (Resident C and Resident E). Findings include: 1. The clinical record for Resident C was reviewed on 10/16/24 at 3:05 p.m. The diagnoses included, but were not limited to, pressure ulcer of left and right buttocks. A care plan, with start date of 6/16/23, indicated Resident C had a urinary catheter due to neurogenic bladder and stage 4 (full thickness) wound. The goal was for him to be free of adverse effects from catheter use. The interventions included, but were not limited to, observe for any signs of complications such as urinary tract infections and record urinary output. A physician's order, dated 11/10/23, indicated to monitor output every shift. A physician's order, dated 11/10/23, indicated Foley catheter care was to be completed each shift. The February 2024…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-21 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure infection control was maintained with hand hygiene during medication administration for 3 of 4 residents observed and failed to ensure staff donned a gown prior to providing activities of daily living (ADL) care for a resident with enhanced barrier precautions (EBP) for 1 of 3 residents reviewed for transmission-based precautions. (Residents 2, 9, 31, and 91) Findings include: 1. An observation was conducted of a medication administration with Licensed Practical Nurse (LPN) 6 for Resident 31 on 10/17/24 at 8:47 a.m. LPN 6 was observed at the medication cart preparing the resident's medication. During that time, she had pulled all the medications from the cart, touched the computer mouse, cups, and water pitcher. She then grabbed a straw and unwrapped the paper wrapper touching the end piece of the straw the resident would place in his mouth with her bare hands. After, LPN 6 was observed entering the resident's room and administering the medications to the resident. The resident did utilize the straw in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-07-25 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure residents were treated with respect and dignity for 2 of 2 residents reviewed for abuse, 2 of 4 residents reviewed for dignity, 1 of 3 residents reviewed for ADLs (activities of daily living,) and 6 of 7 residents that attended in resident council. (Resident 's 1, 5, 8, 14, 21, 29, 19, 31, and 38) Findings include: 1. The clinical record for Resident 21 was reviewed on 7/18/23 at 10:45 a.m. The resident's diagnosis included, but was not limited to, stroke with hemiplegia affecting left side. The Quarterly MDS (Minimum Data Set), completed on 6/17/23, indicated Resident 21 was moderately cognitively impaired. The resident needs extensive assistance of one staff person with dressing. The clinical record for Resident 29 was reviewed on 7/20/23 at 11:45 a.m. The resident's diagnosis included, but was not limited to, heart failure. The Quarterly MDS (Minimum Data Set), completed on 6/27/23, indicated Resident 29 was cognitively intact. An interview was conducted with Resident 21 on 7/18/23 at 11:10 a.m. She…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-07-25 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 timely address a resident's lower extremity edema, timely schedule an orthopedic appointment, to obtain blood sugar readings and administer insulin before meals as ordered, and failed to hold insulin when blood sugar results were below 110, as ordered by the physician, for 1 of 1 resident reviewed for edema, 1 of 3 residents reviewed for ADLs (activities of daily living), 1 of 1 resident reviewed for insulin, and 1 of 5 residents reviewed for unnecessary medications (Residents 5, 14, 31, and 38) Findings include: 1. The clinical record for Resident 38 was reviewed on 7/18/23 at 2:00 p.m. Her diagnoses included, but were not limited to, polyneuropathy. The 7/15/23 skilled nursing assessment indicated she had +1 pitting edema (up to 2 mm of depression, rebounding immediately) in her left and right lower legs. There was no information, including in the progress notes or physician's orders, in the clinical record indicating the lower extremity edema was addressed or that the physician was notified. The 6/6/23…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-25 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
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 initiate a grievance for a resident, to address grievances, to follow up on a resident's grievance, and to ensure their grievance policy included all necessary components for 2 of 4 residents reviewed for abuse and 1 resident reviewed for choices. (Resident 20, 31, and 38) Findings include: 1. The clinical record for Resident 20 was reviewed on 7/19/23 at 9:24 a.m. The Resident's diagnosis included, but were not limited to, end stage renal disease and diabetes. A Quarterly Minimum Data Set Assessment, completed 5/10/23, indicated he was cognitively intact. He could make his needs and wants known and understand what was being said to him, and that he received dialysis. During an interview on 7/19/23 at 9:57 a.m., Resident 20 indicated he was very upset because the facility owed him money and was not giving it back to him. He had attempted to pay his bill and had been informed by the business office that he had a credit to his bill of about $7,000.00. He had asked for a refund but had not received it. During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-25 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure that care plan meetings were conducted quarterly for 1 of 1 resident reviewed for care planning (Resident 20). Findings include: The clinical record for Resident 20 was reviewed on 7/19/23 at 9:24 a.m. The Resident's diagnosis included, but were not limited to, end stage renal disease and diabetes. A Quarterly Minimum Data Set Assessment, completed 5/10/23, indicated he was cognitively intact. He could make his needs and wants known and understand what was being said to him, and that he received dialysis. During an interview on 7/19/23 at 9:24 a.m., Resident 20 indicated he had not attended any care plan meetings. During an interview on 7/21/23 at 10:20 a.m., NC (Nurse Consultant) 1 indicated the last care plan meeting note in the medical record was dated 1/23/23. During an interview on 7/21/23 at 10:45 a.m., the SSD indicated he was unaware of why a care plan meeting had not been held for Resident 20 since 1/23/23. On 7/21/23 at 11:12 a.m., the SSD provided the Resident's First Meeting Guidelines Policy, last…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-25 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to provide showers as ordered for 1 of 4 residents reviewed for Activities of Daily Living (ADL). (Resident 45) Findings include: The clinical record for Resident 45 was reviewed on 7/19/23 at 1:45 p.m. The resident's diagnosis included, but was not limited to, dementia. The Admissions MDS (Minimum Data Set), completed on 4/13/23, indicated Resident 45 was severely cognitively impaired. The resident was total dependence of 1 staff person with bathing and was needing extensive assistance of one staff person with personal hygiene and dressing. An ADL care plan dated 4/18/23 indicated the resident was to receive assistance for ADL tasks. The resident's clinical record did not include a care plan that included interventions in place to address refusals of showers nor preference of a bed bath instead of shower. A physician order dated 4/11/23 indicated the resident was to receive showers Mondays and Thursdays on day shift. A physician order dated 4/11/23 indicated the resident is to be changed from day to night…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure fall interventions were implemented for 1 of 2 residents reviewed for falls and failed to properly orient and train volunteers, who would be assisting residents with mobility affecting 1 of 3 residents reviewed for ADLs (activities of daily living) (Resident 5 and 45) Findings include: 1. The clinical record for Resident 45 was reviewed on 7/19/23 at 1:45 p.m. The resident's diagnosis included, but was not limited to, dementia. The Admissions MDS (Minimum Data Set), completed on 4/13/23, indicated Resident 45 was severely cognitively impaired. A fall care plan dated 4/6/23 indicated Resident 45 was a risk for falling and needed assistance with mobility. The interventions put in place for fall prevention included but was not limited to, non skid socks initiated on 4/10/23, visual signage to use call light initiated on 6/24/23, non slip grip to wheelchair seat initiated on 6/27/23, and urinal at bedside initiated on 7/12/23. A fall event dated 6/24/23 indicated the resident had a fall while transferring…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-25 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to hold a dose of intravenous vancomycin (antibiotic) as instructed by the pharmacy and to communicate the status of needed vancomycin level results to the pharmacy and physician so that an ordered dose of intravenous vancomycin could be administered for 1 of 1 resident reviewed for dialysis (Resident 20). Findings include: The clinical record for Resident 20 was reviewed on 7/19/23 at 9:24 a.m. The Resident's diagnosis included, but were not limited to, end stage renal disease and diabetes. He was admitted to an acute care hospital on 7/1/23 and returned to the facility following hospitalization on 7/4/23. A Quarterly Minimum Data Set Assessment, completed 5/10/23, indicated he was cognitively intact. He could make his needs and wants known and understand what was being said to him, and that he received dialysis. An acute care hospital physician's progress note, dated 7/4/23 at 2:01 p.m. read .patient who presented with complaints of fever and was admitted with a principle diagnosis of Sepsis without acute organ dysfunction,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-25 · tag F0770 — failed to provide lab services — isolatedProvide 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 interview and record review, the facility failed to timely obtain lab, as ordered by a physician, and to timely report lab results to providers for 1 of 1 resident reviewed for dialysis (Resident 20). Findings include: The clinical record for Resident 20 was reviewed on 7/19/23 at 9:24 a.m. The Resident's diagnosis included, but were not limited to, end stage renal disease and diabetes. He was admitted to an acute care hospital on 7/1/23 and returned to the facility following hospitalization on 7/4/23. A Quarterly Minimum Data Set Assessment, completed 5/10/23, indicated he was cognitively intact. He could make his needs and wants known and understand what was being said to him, and that he received dialysis. The Current Discharge Medication List sent from the acute care hospital on 7/4/23 indicated Resident 20 was to receive vancomycin in dextrose 5% (type of intravenous fluid) 1 gram/250 ml (milliliter). Inject 1,000 mg into the vein 3 time a week for 4 days. Give after dialysis, on dialysis days only (Tuesday, Thursday, and Saturday). Start taking on July 6, 2023. 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to TRILOGY HEALTH SERVICES — 123 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 4.2 | -0.2 vs chain |
| Health inspection | 3 of 5 | 3.5 | -0.5 vs chain |
| Staffing | 2 of 5 | 3.3 | -1.3 vs chain |
| Quality measures | 5 of 5 | 4.8 | +0.2 vs chain |
The other 122 homes this chain runs (chain average 4.2★, per CMS)
Showing 40 of 122; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| WITHAM MEMORIAL HOSPITAL | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/01/2015 |
| BAYSTON, BRETT | Individual | CORPORATE DIRECTOR | — | since 01/01/2023 |
| BRAND, JOHN | Individual | CORPORATE DIRECTOR | — | since 01/01/2015 |
| CASTETTER, ANDREA | Individual | CORPORATE DIRECTOR | — | since 01/01/2023 |
| HAWKINS, CLAUDE | Individual | CORPORATE DIRECTOR | — | since 09/09/2013 |
| HORNBECKER, MICHAEL | Individual | CORPORATE DIRECTOR | — | since 01/01/2024 |
| REAGAN, JULIE | Individual | CORPORATE DIRECTOR | — | since 09/25/2024 |
| BARDOCZI, STEPHEN | Individual | CORPORATE OFFICER | — | since 09/03/2013 |
| BRAVERMAN, KELLY | Individual | CORPORATE OFFICER | — | since 12/01/2021 |
| SELLERS, DANIEL | Individual | CORPORATE OFFICER | — | since 06/21/2024 |
| RHS PARTNERS OF ARLINGTON LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2015 |
| BLACKWELL, CORY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/15/2025 |
| YASSIN KASSAB, MAHMOUD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/16/2025 |
| BARNEY, LEIGH | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 09/19/2025 |
| DAVIS, DAVID | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 09/19/2025 |
| AMERICAN HEALTHCARE REIT HOLDINGS LP | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| AMERICAN HEALTHCARE REIT INC | Organization | ADP OF THE SNF | — | since 10/01/2018 |
| CONTINENTAL MERGER SUB LLC | Organization | ADP OF THE SNF | — | since 10/01/2021 |
| GAHC3 TRILOGY JV LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| GAHC4 TRILOGY JV LLC | Organization | ADP OF THE SNF | — | since 10/01/2018 |
| MS ARLINGTON, L.P. | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| PARAGON OUTPATIENT REHABILITATION SERVICES LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY INVESTORS LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY MANAGEMENT SERVICES LLC | Organization | ADP OF THE SNF | — | since 09/19/2025 |
| TRILOGY PROPCO MASTER TENANT III LLC | Organization | ADP OF THE SNF | — | since 07/16/2025 |
| TRILOGY REAL ESTATE INVESTMENT TRUST | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY REIT HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
CMS files one row per role, so the 29 rows in the source record cover these 27 parties — each is shown once here with every role it holds. Nothing is omitted.
14 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.
This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 12% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Indiana Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 155816. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-08, 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.