Clearvista Lake Health Campus
8405 Clearvista Place, Indianapolis, IN 46256 · Government - County · 70 certified beds · (317) 578-7500 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 1 actual-harm citation
- a high number of inspection citations overall (27) — 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
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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 | 4 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.
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 | 7.4% | 11.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.4% | 5.5% | 5.4% | better |
| 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 | 0.8% | 1.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 12.2% | 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 | 3.2% | 3.9% | 3.3% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 9.9% | 23.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 81.8% | 95.4% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 0.9% | 3.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 28.4% | 23.3% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 1.5% | 13.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.9% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 81.2% | 79.0% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 21.2% | 22.2% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 13.7% | 10.8% | 12.0% | 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.
63.5% 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 158 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 60.6% 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 71 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 0.52 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 12% 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 | 63.5%CMS range 54.9–70.5 | 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 | 10.2%CMS range 7.0–15.1 | 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 | 60.6% | 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 | 60.6% | 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 | 56.3% | 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 | 100.0% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 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 | 6.0%CMS range 3.5–10.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.99 | 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 70 beds and averages 48.2 residents a day — about 69% occupied, or roughly 22 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 3.75 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.83 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.91 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 3.05 hrs/resident/day on weekends vs 4.03 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 0.94 to 0.56 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 50% 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · G2023-08-22 · tag F0790 — failed to provide dental care — isolatedProvide routine and 24-hour emergency dental care for each resident.
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 timely assist in arranging emergency dental services for a resident with an abscessed tooth resulting in a delay of dental services for the abscessed tooth which was painful and infected 1 of 1 Resident reviewed for Dental (Resident 2). Findings include: The clinical record for Resident 2 was reviewed on 8/16/23 at 1:30 p.m. The Resident's diagnosis included, but were not limited to, dementia and dysphagia (difficulty swallowing). She was admitted from an acute care hospital to the facility on 7/7/23. Resident 2 resided in the facilities attached memory care assisted living prior to her hospitalization. A nursing progress note, dated 7/9/23 at 6:17 p.m., indicated a family member informed staff member that Resident 2 was to have oral surgery prior to her hospitalization. Resident 2 had multiple teeth which needed extracted. A follow up appointment needed to be scheduled as soon as possible. An assessment of Resident 2 revealed pain 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.
- Potential for harm · Fcited before2026-01-12 · 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 monitoring of the dishwasher sanitation and maintain clean kitchen flooring. This had a potential to effect 44 of 44 residents that reside in the skilled facility. Findings include: An observation of the kitchen was made with the Dietary Manager (DM) on 1/5/26 at 9:43 a.m. The dishwasher was observed during washing and rinsing cycles. The DM had indicated she had been having trouble with the dishwasher for several months. The service technician had been out to service the machine. The dish machine was a high temperature dishwasher, but with the problems it was having the service technician recommended using it as a low temperature dishwasher until replacement. The dishwasher has been working as a low temperature dishwasher for a couple months. The staff were currently utilizing chemical strips to ensure the sanitation was appropriate. The staff use an electronic charting to document the washing and sanitation temperatures. At that time, [NAME] 5 indicated he checks the dishwasher sanitation nightly.…
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 before2026-01-12 · 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 ensure a self medication assessment was completed timely for 2 of 2 residents randomly observed for self medication (Residents 4 and 14)Findings include: 1 The clinical record for Resident 14 was reviewed on 1/5/26 at 10:20 a.m. The resident's diagnosis included, but was not limited to, hypertension. On 1/5/26 at 10:20 a.m., Resident 14 was observed in her room sitting in her wheelchair. A plastic medication cup with 4 pills inside of it was sitting on her overbed table. Resident 14 indicated the nurse had left her medication for her to take. She then put the 4 pills into her mouth and swallowed them with a drink of water. Resident 14 indicated the nurses' usually left her medication for her to take when she was ready. A Self Administration of Medication Assessment, dated 1/5/26 at 12:51 p.m., indicated Resident 14 could self administer all oral medications and that her medications would be kept on the medication cart. The resident's self administration of medication assessment was conducted after 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 · Dcited before2026-01-12 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a safe method of transfer for 1 of 2 residents reviewed for falls. (Resident 1) Findings include: The clinical record for Resident 1 was reviewed on 1/5/26 at 1:30 p.m. The diagnoses for Resident 1 included, but were not limited to, vascular dementia, muscle weakness, rheumatoid arthritis and osteoporosis (bone disease that causes bones to become weak, thin and brittle). A Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident 1 needed staff to provide half of the assistance with lifting, holding, and trunk or limb support for the resident in a lying to a sitting position. The staff needed to provide all assistance with lifting, hold and trunk or limb support for the resident sitting to standing position and bed to chair positioning. A fall care plan, dated 2/19/25, indicated Resident 1 was a fall risk related to muscle weakness and dementia. The interventions included but were not limited to, start date: 2/19/25, staff to assist…
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 before2026-01-12 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
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 timely notify a physician of a resident with pain, timely receive scheduled pain medications from the pharmacy, and to assess pain level, location of pain, and non-pharmacological interventions attempted prior to administering prn medications for 2 of 2 residents reviewed for pain. (Residents 26 and 63) Findings include: 1. The clinical record for Resident 63 was reviewed on 1/5/26 at 1:54 p.m. The resident's diagnosis included, but were not limited to, back pain and lumbar post-laminectomy syndrome (persistent pain or neurological symptoms in the back or extremities after spinal surgery). She was admitted to the facility on [DATE]. Resident 63 had an intrathecal pain pump (device that delivers pain medication to the fluid around the spinal cord) which delivered hydromorphone (narcotic pain medication) due to chronic pain. A physician's order, dated 12/26/25, indicated she was to receive cyclobenzaprine (Flexeril muscle relaxer) 10 mg tablet three…
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 before2024-11-12 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 apply TED hose (stockings that help prevent blood clots and swelling in the legs) as ordered for 1 of 1 resident reviewed for edema and to hold blood pressure medication, as ordered by the physician, for 2 of 5 residents reviewed for unnecessary medications. (Resident 3, Resident 9, and Resident 13) Findings include: 1. The clinical record for Resident 13 was reviewed on 11/7/24 at 10:53 a.m. The diagnoses included, but were not limited to, edema. A care plan, dated 9/23/24, indicated the resident was to wear TED hose to her legs. A physician order, dated 9/17/24, indicated the staff was to apply TED hose to the resident's legs in the morning and remove them at night. Observations were made of Resident 13 on 11/7/24 at 10:53 a.m., 11/7/24 at 2:15 p.m., 11/8/24 at 9:38 a.m., and 11/8/24 at 1:21 p.m. The resident was observed wearing shoes, but she was not wearing TED hose. An observation was made of Resident 13 in her room with Certified Resident Care Associate (CRCA) 5 on 11/8/24 at 1:23 p.m. The resident 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.
- Potential for harm · Dcited before2024-11-12 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a resident's pain was assessed for severity of her pain for 1 of 3 residents reviewed for catheter. (Resident 25) Findings include: The clinical record for Resident 25 was reviewed on 11/6/24 at 12:20 p.m. The diagnoses included, but were not limited to, diabetes mellitus with diabetic polyneuropathy. A care plan for pain, dated 12/18/23, indicated At risk for pain r/t [related to] diabetic polyneuropathy, depression, repeated falls. The approach included, but was not limited to, observe for and record verbal and non-verbal signs of pain. A physician order, dated 10/2/24, indicated the staff was to administer five milligrams of oxycodone prior to wound care once a day as needed. A physician order, dated 11/5/24, indicated the staff was to cleanse wounds on Resident 25's right and left heels with anasept (wound cleanser); apply skin prep to peri-wounds; apply collagen to wound beds; cover with absorbent dressings; and wrap with kerlix and secure with tape. The dressing changes were scheduled for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-12 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the medication and/or supply storage rooms did not contain expired supplies for 1 of 2 medication rooms observed and 1 of 2 central supply rooms observed. Findings include: An observation was conducted of the central supply room on [NAME] unit with the Director of Nursing (DON) on 11/7/24 at 9:40 a.m. There were 16 cartons of Osmolite 1.5 (feeding solution) with an expiration date of 11/1/24. The DON indicated the facility did not have any residents currently receiving Osmolite 1.5. The Scheduler was responsible for supply storage. An observation was conducted, on 11/7/24 at 9:55 a.m., of the medication storage room on the Hinkle unit with Licensed Practical Nurse (LPN) 2. A cabinet contained ten COVID tests that had expired in 2023. A policy titled MEDICATION STORAGE IN THE FACILITY, revised 11/18, was provided by the DON on 11/7/24 at 1:48 p.m. The policy indicated the following, .E. The medication administration personnel will…
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 before2024-11-12 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure residents' medical records were complete and accurate with behavior monitoring and documentation of urine characteristics after insertion of a Foley catheter for 2 of 5 residents reviewed for unnecessary medications and 1 of 3 residents reviewed for catheters. (Residents' 11, 25, and 26) Findings include: 1a. The clinical record for Resident 25 was reviewed on 11/6/24 at 12:20 p.m. The diagnoses included, but were not limited to, diabetes mellitus with diabetic polyneuropathy and obstructive and reflux uropathy (blocks the flow of urine). A physician order, dated 5/8/24, indicated the staff was to change the resident's Foley catheter every 30 days. The November 2024 Treatment Administration Record indicated the resident's Foley catheter was changed on 11/8/24. A nursing progress note, dated 11/8/24, indicated the following, Anchored 16 FR [French] 10 cc [cubic centimeter] bulb catheter change for the month. Resident tolerated it well. Resident 25's clinical record did not include characteristics of the resident'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 · Dcited before2024-11-12 · 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 Foley catheter care for 1 of 3 residents reviewed for catheters. (Resident 3) Findings include: The clinical record for Resident 3 was reviewed on 11/7/24 at 11:00 a.m. The diagnoses included, but were not limited to, neuromuscular dysfunction of bladder and stage 3 kidney disease. A care plan, dated 6/10/24, indicated the Resident uses a suprapubic or Foley catheter for dx [diagnosis] of: Neurogenic Bladder. The approaches included, but were not limited to, Provide assist with catheter care and change Foley catheter per physician orders. A physician order, dated 6/10/24, indicated the staff was to provide catheter care to Resident 3 three times a day. An observation was conducted of Foley catheter care with Certified Resident Care Associate (CRCA) 3 and the Director of Nursing on 11/12/24 at 1:43 p.m. CRCA 3 was observed washing his hands and donning on gloves prior to catheter care. Then, he turned on the faucet, filled a basin of water 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.
- Potential for harm · D2024-11-12 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake 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
Based in observation, interview, and record review, the facility failed to ensure resident rooms were in good repair for 2 of 3 resident rooms reviewed for environment (Resident 15 and 29). Findings include: 1a. Resident 15's room was observed on 11/7/24 at 9:51 a.m. The drywall behind her bed had been patched. The area was unpainted and appeared bumpy and uneven. On 11/12/24 at 2:28 p.m., Resident 15's room was observed with the Executive Director (ED). The ED indicated the drywall behind Resident 15's bed had been patched. The wall had been repaired multiple times. Resident 15 utilized a trapeze to assist with bed mobility and the trapeze stand caused the drywall to become scratched. 1b. Resident 29's room was observed on 11/7/24 at 11:00 a.m. The wall behind his bed had an irregularly shaped white area present on it. On 11/12/24 at 2:40 p.m., Resident 29's room was observed with the ED and the Director of Plant Operations (DOP). The DOP indicated the white area on the wall behind the bed was from the bed scraping against the wall. The paint had been worn away. The DOP was unsure…
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 16 citations
- Potential for harm · D2024-06-21 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a comfortable, homelike environment for 1 of 37 residents in the facility. (Resident C) Findings include: An observation of Resident C's room was conducted on 6/21/24 at 11:17 a.m. During the observation, two, small crawling insects, which appeared like ants, were crawling up the wall in between the P-[NAME] (air conditioner/heating unit) and the windowsill in Resident C's room. The two ants on the wall crawled under the windowsill and disappeared. Another small, crawling insect, which appeared like an ant, was found crawling on the floor and disappeared in between the flooring planks. An interview with Nurse Consultant (NC) conducted, on 6/21/24 at 11:03 a.m., indicated the facility did have an issue with ants in a resident's room. The facility had not called out their pest control company to spray the inside of the room, instead they decided to handle it internally and have the maintenance department spray inside the resident'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 · Dcited before2024-06-21 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 interview and record review, the facility failed to ensure a resident's wound was maintained free of contamination by ants for 1 of 3 residents reviewed for wounds. (Resident B) Findings include: The clinical record for Resident B was reviewed on 6/21/24 at 9:55 a.m. The resident's diagnoses included, but were not limited to, traumatic brain injury and seizure disorder. He was receiving hospice care and passed away on 6/6/24. A physician's order, dated 4/5/24, indicated to cleanse the wound on his left knee with normal saline, pat dry, and apply skin prep (skin protecter) around the wound, cover the wound bed with Therahoney (wound treatment gel made of honey), and apply a dry dressing. Instructions were to change the dressing every 3 days. A CAR (Clinically at Risk) note, dated 5/24/24, indicated Resident B's left knee wound was from trauma. The wound had 70% necrotic (dead) tissue and 30 % granulation tissue (new tissue). A Hospice LPN (Licensed Practical Nurse) Visit with Wound note, dated 6/5/24, indicated the following, .SN [Skilled Nursing] routine visit this date. Pt…
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 before2024-06-21 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure a wound treatment order was placed timely for 1 of 3 residents reviewed for wound care. (Resident C) Findings include: An observation of Licensed Practical Nurse (LPN) 2 preparing to complete wound care on Resident C was conducted on 6/21/24 at 11:17 a.m. LPN 2 began by pulling out the supplies and medications needed to complete Resident C's wound care. In doing so, LPN 2 had pulled from the medication/treatment cart three tubes of medication and dispensed a small amount from each tube into its own medication cup. Upon entering Resident C's room, Resident C was lying on his bed and was turned towards the wall. Resident C's wounds on his buttocks were visible. The wounds on his buttocks had opened areas that were red in color. The clinical record for Resident C was reviewed on 6/21/24 at 12:08 p.m. Resident C's diagnoses included, but not limited to, weakness and a contracture of right knee (inability to move). A physician's order, dated 6/13/24, indicated to apply Silvadene cream 1% (an antimicrobial…
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 before2024-06-21 · 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 maintain an infection prevention and control program by touching the tip of a medication tube with a bare finger, not performing hand hygiene with glove use, and not wearing proper personal protective equipment (PPE) when providing incontinence care to a resident in enhanced barrier precautions (EBP) (an infection control strategy to reduce the spread of multi-drug resistant organisms during high-contact care activities) for 1 of 3 residents reviewed for wounds. (Resident C) Findings include: An observation of Licensed Practical Nurse (LPN) 2 preparing to complete wound care on Resident C was conducted, on 6/21/24 at 11:17 a.m. LPN 2 began by pulling out the supplies and medications needed to complete Resident C's wound care. LPN 2 pulled from the medication/treatment cart three tubes of medication and dispensed a small amount from each tube into its own medication cup. However, when doing so, the tube of miconazole nitrate still had the foil seal attached to the tube partially and LPN 2 moved the foil seal…
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 before2024-05-03 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 interview and record review, the facility failed to ensure a resident was provided timely care and/or services in accordance with professional standards of practice for a resident who experienced an unwitnessed fall within the facility for 1 of 3 residents reviewed for falls. (Resident M) Findings include: The clinical record for Resident G was reviewed on 5/3/24 at 2:39 p.m. Resident M's diagnoses included, but not limited to, cerebrovascular accident (CVA, stroke), fibromyalgia (widespread body pain), hypertension (high blood pressure) and dementia. A nursing note dated 3/20/24 at 8:25 a.m. indicated, Resident M had an unwitnessed fall and was found on the floor between her bed and the bedside table by a staff member. No injuries were noted at the time and the resident had no complaints of pain per the nursing note. A physician's note dated 3/21/24 at 9:16 a.m. and recorded as a late entry on 3/26/24 at 9:16 a.m. indicated, Resident experienced an unwitnessed fall [sic, and] was found on the floor in her room. No signs or symptoms of obvious injury. Mentation at baseline.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-12 · 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 interview and record review, the facility failed to ensure a gait belt was utilized for transferring a resident who lost their balance and fell onto the bathroom floor for 1 of 3 residents reviewed for accidents. (Resident B) Findings include: The clinical record for Resident B was reviewed on 12/12/23 at 3:25 p.m. The diagnoses included, but were not limited to, chronic lung disease, depression, hypertension, macular degeneration, and osteopenia. A Quarterly Minimum Data Set (MDS) assessment, dated 8/31/23, indicated severe cognitive impairment, extensive assistance with two staff for transfer, and extensive assistance with one staff for toilet use. Resident B was listed as not steady with moving on and/or off the toilet. A fall risk care plan, start date of 7/19/23, indicated Resident B was at risk for falling related to impaired mobility due to generalized weakness, asthma with shortness of breath, impaired vision related to macular degeneration and glaucoma. The approaches listed included, but were not limited to, encourage resident to assume standing position slowly…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-08-22 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prime an insulin flex pen prior to administering insulin for 1 of 5 residents observed during administration of medications, ensure monitoring of bowel and bladder outputs for 1 of 2 residents reviewed for hospitalization and 1 of 1 residents reviewed for constipation, and to administer antibiotics, as ordered by a physician, for 1 of 1 resident reviewed for dental (Residents' 2, 9, 35 and 142) Findings include: 1. The clinical record for Resident 35 was reviewed on 8/21/23 at 9:00 a.m. The diagnosis for Resident 35 included, but was not limited to, diabetes mellitus type 2. A physician order indicated the resident was to receive a sliding scale of insulin aspart. The sliding scale was the following: blood sugar reading of 151 to 200 = 3 units, blood sugar reading of 201 to 250 = 5 units, blood sugar reading of 251 to 300 = 8 units, blood sugar reading of 301 to 350 = 10 units, and blood sugar reading of 351 to 400 = 12 units, 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 · Ecited before2023-08-22 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and record review the facility failed to serve pureed food at appropriate temperatures with the potential to affect 7 of 37 residents residing at the facility. Findings include: The lunch service was observed with the Dietary Manager on 8/18/23 at 11:42 a.m. The pureed food temperatures were obtained while the food was on the steam table for service. The pureed ham was 102 degrees Fahrenheit, the pureed sweet potatoes were 100 degrees Fahrenheit, and the pureed greens were 100 degrees Fahrenheit. During an interview at 11:50 a.m., the Dietary Manager indicated the temperature at serving should be at least 145 degrees Fahrenheit. The pureed meal had already been served to a couple of residents. It would be reheated. The pureed meal had been 171 degrees Fahrenheit when it was removed from the oven. There should have been a cover over the food to assist in maintaining the temperatures. During an interview on 8/21/23 at 11:36 a.m., Nurse Consultant 2 indicated there were 7 residents of the health center who received a pureed diet. 3.1-21(a)(2)
- Potential for harm · Dcited before2023-08-22 · 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 have the interdisciplinary team determine and document self administration of medications was clinically appropriate for 1 of 5 residents observed during medication administrations. (Resident 190) Findings include: The clinical record for Resident 190 was reviewed on 8/22/23 at 9:00 a.m. The diagnosis for Resident 190 included, but was not limited to, stroke. A physician order dated 8/20/23 indicated Resident 190 was able to receive 2 tabs of 500 milligrams of Tums three times a day as needed. During a medication administration with License Practical Nurse (LPN) 11 on 8/22/23 at 8:35 a.m., an observation was made of LPN 11 preparing medication for Resident 190. After, LPN 11 entered the resident's room and administered the pill medications he had prepared to the resident. During that time, an additional medication cup was observed at the resident's bedside with a green chewable tablet. The resident indicated to LPN 11 she needed something for upset stomach. LPN 11 left the room and returned to the medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-22 · tag F0559 — isolatedHonor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
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 inform a resident of a room change, prior to it being initiating, for 1 of 1 resident reviewed for abuse (Resident 10). Findings include: The clinical record for Resident 10 was reviewed on 8/16/23 at 2:44 p.m. The Resident's diagnosis included, but were not limited to, anxiety and dementia. A care plan, initiated on 8/14/22, indicated that Resident 10 had impaired cognition, which fluctuates, and impaired short-term memory, with risk for confusion, disorientation, altered mood, and impaired or reduced safety awareness related to dementia. The goal was that she would remain safe and not injure herself secondary to impaired decision making. The interventions, initiated 8/14/22, included to re-direct her when agitated behaviors are present or a potential for injury is evident, pay attention to basic needs and provide ADL (Activities of Daily Living) care as required, provide cues and supervision for decision making, in new situations, provide support 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.
- Potential for harm · D2023-08-22 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments completed regarding Dental concerns for 1 of 1 resident reviewed for dental, Preadmission Screening and Resident Review (PASRR) for 1 of 1 resident reviewed for MDS Accuracy, assistance with eating for 1 of 2 residents reviewed for Activities of Daily Living and Discharge MDS accuracy for 1 of 1 resident reviewed for discharge (Resident 2, 9, 18 and 38) Findings include: 1. The clinical record for Resident 2 was reviewed on 8/16/23 at 1:30 p.m. The Resident's diagnosis included, but were not limited to, dementia and dysphasia (difficulty swallowing). She was admitted from an acute care hospital to the facility on 7/7/23. A nursing progress note, dated 7/9/23 at 6:17 p.m., indicated an assessment of Resident 2 revealed pain to mouth and throat and a large, abscess-like area along the gum line on the bottom left side of her mouth. A physician's progress note, dated 7/10/23 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 · D2023-08-22 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
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 prepare a discharge summary that included a recapitulation of the resident's stay, a final summary of the resident's status, a reconciliation of all pre and post discharge medications, and a discharge plan of care for 1 of 1 resident reviewed for discharge. (Resident 38) Findings include: The clinical record for Resident 38 was reviewed on 8/21/23 at 10:27 a.m. Her diagnoses included, but were not limited to, chronic obstructive pulmonary disease and depression. She was admitted to the facility on [DATE] and discharged to an assisted living facility on 6/26/23 at 12:35 p.m. The 5/22/23 Resident First Meeting note indicated Resident 38's discharge plan was unknown due to her physical decline. The 6/22/23, 1:30 p.m. social services note, written by the SSD (Social Services Director) and recorded as a late entry on 6/28/23 at 9:20 a.m., read, On this date writer received a call from [name of assisted living facility's] admission director, requesting…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-22 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide showers for 1 of 2 residents reviewed for Activities of Daily Living. (Resident 140) Findings include: The clinical record for Resident 140 was reviewed on 8/16/23 at 2:00 p.m. The diagnosis for Resident 140 included, but was not limited to, stroke. The resident was admitted on [DATE]. A nursing progress note dated 8/9/23 indicated Resident was alert and oriented. A life enrichment assessment dated [DATE] indicated it was very important to the resident to choose bathing type. Resident 140 chose to receive showers. An observation was made of Resident 140 on 8/16/23 at 1:25 p.m. The resident's hair was observed to be greasy with white flakes in her hair. An interview was conducted with Resident 140 on 8/16/23 at 1:31 p.m. She indicated she had not received a shower since she was admitted to the facility. She would love to have a shower. The staff have washed her up, but she had not received a shower. An interview was conducted with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-22 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement care planned fall intervention and to include therapy recommendations to the care plan for 1 of 1 resident reviewed for accidents. (Resident 29) Findings include: The clinical record for Resident 29 was reviewed on 8/16/23 at 2:11 p.m. The Resident's diagnosis included, but were not limited to, Huntington's disease (disease of nervous system) and history of falling. A care plan, initiated 2/24/22, indicated he was at risk for falling related to his impaired cognition, restlessness, and exit seeking. The goal was for him to remain free from falls with major injury. The approaches were to have fall mat at bedside, initiated 6/28/23, footboard to bed to assist with boundaries, initiated 5/15/23, staff to offer to lay resident down after meals upon request, initiated 8/16/23, provide sandwich/snack around midnight hours if awake, initiated 5/12/2023, offer to toilet after dinner, initiated 4/24/2023, ensure resident is given…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-22 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to coordinate a resident's medication administration times with their dialysis schedule and complete post dialysis assessments, as ordered, for 1 of 1 resident reviewed for dialysis. (Resident 14) Findings include: The clinical record for Resident 14 was reviewed on 8/21/23 at 3:06 p.m. His diagnoses included, but were not limited to, end stage renal disease. The dialysis care plan, last reviewed/revised 8/21/23, indicated an approach was to coordinate care with the dialysis center. His dialysis days were Tuesday, Thursday, and Saturday. An observation of Resident 14's room was made on Tuesday, 8/22/23, at 10:30 a.m. He was not present in his room. An interview was conducted with LPN (Licensed Practical Nurse) 6 on 8/22/23 at 10:31 a.m. He indicated Resident 14 was currently at dialysis and usually returned between 11:00 a.m. and 12:00 p.m. The physician's orders indicated to administer one 500 mg tablet of Tylenol Extra Strength three times a day, starting 12/14/20; one 25 mg tablet of Sertraline once a day, starting 8/9/21;…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-22 · 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 during medication administration for 1 of 5 residents observed during medication administration and failed to ensure urinary catheter tubing and drainage bags were not touching the floor for 1 of 1 resident reviewed for urinary catheter. (Resident 2 and 35) Findings include: 1. The clinical record for Resident 35 was reviewed on 8/21/23 at 9:00 a.m. The diagnosis for Resident 35 included, but was not limited to, diabetes mellitus type 2. A physician order indicated the resident was to receive a sliding scale of insulin aspart. The sliding scale was the following: blood sugar reading of 151 to 200 = 3 units, blood sugar reading of 201 to 250 = 5 units, blood sugar reading of 251 to 300 = 8 units, blood sugar reading of 301 to 350 = 10 units, and blood sugar reading of 351 to 400 = 12 units An observation was made of a medication administration with License Practical Nurse (LPN) 6 on 8/21/23 at 11:22 p.m. LPN 6 was observed preparing to administer insulin utilizing 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 07/01/2015 |
| 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 06/20/2024 |
| RHS PARTNERS OF CASTLETON LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2015 |
| MEVZEK, STACY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/14/2025 |
| 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 10/01/2021 |
| AMERICAN HEALTHCARE REIT INC | Organization | ADP OF THE SNF | — | since 10/01/2018 |
| 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 CASTLETON, 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 11/05/2025 |
| TRILOGY PROPCO MASTER TENANT III LLC | Organization | ADP OF THE SNF | — | since 07/14/2025 |
| 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 |
| DURHAM-BORING, TAMMY | Individual | ADP OF THE SNF | — | since 07/14/2025 |
CMS files one row per role, so the 28 rows in the source record cover these 26 parties — each is shown once here with every role it holds. Nothing is omitted.
13 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 $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 11% 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 155815. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-12, 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 →
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