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Creekside Health And Rehabilitation Center

3114 East 46th Street, Indianapolis, IN 46205 · For profit - Corporation · 120 certified beds · (317) 920-7888 Medicare & Medicaid certified

Call the home — (317) 920-7888 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Resident-funds citation (F0565)1 actual-harm citation
Insights

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

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has a citation for mishandling residents’ money or property (F0565)
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • about 23% of its spending goes to commonly-owned related companies

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

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

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Urgent care / clinic
3901 Meadows Dr · (317) 880-2700 · Call to confirm hours
Pharmacy
2330 E 46th St · (317) 253-1636 · Call to confirm hours
Grocery
4810 N Dearborn St
Park
Typically dawn to dusk
Place of worship
2902 E 46th St · (317) 541-8582

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 1 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased2.3%11.0%15.4%better
Long-stay residents who lose too much weight6.1%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder1.7%0.4%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.3%1.1%2.0%better
Long-stay residents with depressive symptoms3.3%25.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.2%3.9%3.3%better
Long-stay residents whose ability to walk worsened2.8%11.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication12.6%23.5%18.9%better
Long-stay residents given the seasonal flu vaccine92.0%95.4%95.3%typical
Long-stay residents with pressure ulcers2.6%3.6%4.7%better
Long-stay residents with worsening bladder/bowel control25.7%23.3%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table9.0%13.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.8%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine90.5%79.0%79.4%better
Short-stay residents rehospitalized after admission25.8%22.2%22.6%worse
Short-stay residents with an outpatient ER visit6.2%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.

52.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 113 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

52.8%U.S. median 51.5%
Got home and stayed home
9.9%U.S. median 10.7%
Went back to hospital
60.4%U.S. median 56.6%
Met the expected recovery
0.32U.S. median 0.31
Therapy hours / resident / day
0.18hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 60.4% 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 48 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 0.32 therapist hours per resident per day in 2026Q1 — more than 52% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF52.8%CMS range 43.8–61.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.9%CMS range 6.7–14.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge60.4%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge81.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge54.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting97.1%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened9.1%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.0%CMS range 3.6–11.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.981.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.52
RN hours/ resident / day
1.03
LPN hours/ resident / day
2.46
Aide hours/ resident / day
4.01
Total nurse hours/ resident / day
0.39
RN hoursweekends
53.6%
Total nursing turnover
37.5%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 109.6 residents a day — about 91% occupied, or roughly 10 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.01 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.52 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.46 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.31 hrs/resident/day on weekends vs 4.29 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.57 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%.

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

Inspection trend

6
deficiencies at the latest standard inspection (2026-02-11)
5
at the previous standard inspection (2025-01-15)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

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

  • Actual harm · Gcited before2025-01-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide a resident with adequate assistance of two staff members for bed mobility during perineal care resulting in a fall from bed, and ensure a transfer from the wheelchair to the toilet was performed in accordance with the plan of care for 2 of 4 residents reviewed for accidents and 1 of 5 residents reviewed for Activities of Daily Living (ADLs). This deficient practice resulted in Resident 60 falling and sustaining a fracture of the left upper arm. (Resident 1, Resident 60, and Resident B) Findings include: 1a. The clinical record for Resident 60 was reviewed on 1/9/25 at 9:55 a.m. The diagnoses included, but were not limited to, bone density disorder, abnormalities of gait and mobility, muscle weakness, difficulty in walking, and stroke with hemiplegia (paralysis one side of body) affecting left non-dominant side. The Annual Minimum Data Set (MDS) assessment, dated 8/7/24, indicated Resident 60 was cognitively intact. The resident had impairment on upper and lower of one side of the body. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-26 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to correctly document a resident's anti-psychiatric medication use on the annual Minimum Data Set assessment for 1 of 4 residents reviewed for use of accuracy of assessments. (Resident D) Findings include:The clinical record of Resident D was reviewed on 3-26-26 at 12:25 p.m. Her diagnoses included, but were not limited to delusional disorder (serious psychotic disorder characterized by the presence of one or more fixed, false beliefs that persist for at least one month) and anxiety. The annual Minimum Data Set (MDS) assessment (a tool to track, review, and report the high-risk medications a nursing home resident received), dated 2-6-26, indicated under the medication section, the resident had not received any anti-psychotic medications. A review of Resident D's physician orders, revised on 9/5/25, indicated the resident was prescribed, by the physician, risperidone .025 milligrams twice daily (an anti-psychotic medication) for a diagnosis of delusional disorder. The medication administration records (MAR) for January 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-02-11 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure the residents' dignity was maintained and respected by not using cell phones while assisting with eating (Resident ZZ), and staff turning off the call lights and not returning to the residents' room to provide the services that had been requested (Residents' C, D, E, F, G, H, J, K, L, M, N, P, Q, R, S, T, and V) for 18 of 109 residents reviewed for dignity. Findings include: 1.The Resident Council Minutes binder was provided by the Activities Director on 2/5/26 at 11:00 a.m. The council minutes, dated November 20, 2025, indicated staff were turning off the call lights and not providing the service requested. A resident council meeting was conducted on 2/5/26 at 1:36 p.m. The resident attendees were Residents' C, D, E, F, G, H, J, K, L, M, N, P, Q, R, S and T. During the meeting, they indicated call light response was a problem. It had been brought up in previous resident council meetings and had not been addressed. The staff would come into the room, turn the call light off and indicate they would let…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-02-11 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to timely address a resident's skin condition; to ensure a resident's fall interventions were implemented; to obtain a resident's heart rate and medication hold perimeters were followed; address a resident's ear wax buildup; to ensure weights were obtained and the provider was notified of out of parameter weights for 5 of 10 residents reviewed for Quality of Care. (Residents BB, 86, 3, E, and V) Findings include: 1 The clinical record for Resident BB was reviewed on 2/5/26 at 2:52 p.m. The resident's diagnosis included, but was not limited to, quadriplegia (loss of sensation and function of all four limbs and torso). A Quarterly Minimum Data Set (MDS) Assessment, completed 11/10/25, indicated he was cognitively intact, frequently incontinent of urine, and dependent for toilet hygiene. He had no moisture associated skin damage (MASD). A shower sheet, dated 12/2/25, indicated Resident BB had a bed bath. There were no skin areas of concern marked on the shower sheet. A shower sheet, dated 12/9/25, indicated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-02-11 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure staff donned Personal Protective Equipment(PPE) prior to entering a room of a resident in contact isolation precautions and prior to performing tracheostomy care for a resident in enhanced barrier precautions, to ensure hand hygiene was performed after doffing (removing) gloves, and to ensure a resident's catheter bag was correctly positioned for 1 resident randomly observed for contact isolation, 1 of 1 resident reviewed for tracheostomy and 2 of 2 residents reviewed for urinary catheter care (Resident 22, Resident 1,and Resident 80).Findings include:1 The clinical record for Resident 22 was reviewed on 2/9/26 at 3:21 p.m. The resident's diagnosis included, but was not limited to, hypertension (high blood pressure). On 2/9/26 at 3:21 p.m., Resident 22's room was observed to have a sign posted on the door frame that indicated she was in Contact Isolation Precautions. An isolation cart was located outside of her door and contained disposable gowns and gloves. Registered Dietician (RD) 4 did not have 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-11 · tag F0687 — failed to care for feet properly — isolated
    Provide appropriate foot care.
    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 was provided with heel protective boots, as ordered, and ensure timely follow-up with podiatry services for 1 of 3 residents reviewed for foot care. (Resident V) Findings include: The clinical record for Resident V was reviewed on 2/6/26 at 12:00 p.m. The resident's diagnoses included, but were not limited to, cerebral palsy (neurological disorder that permanently affects body movement), seizure disorder (recurrent, unprovoked seizures), and aphasia (impaired ability to speak, write, and understand language). An interview was conducted with Family Member 4 on 2/6/26 at 12:01 p.m. The family member indicated there was an ongoing issue at the facility with them not trimming Resident V's toenails.The ADL care plan, with a revision date of 8/26/25, indicated Resident V required total staff assistance with his activities of daily living. The current physician's order, dated 3/24/20, indicated the resident was to always have Prevalon boots (a heel protection boot for pressure relief) on every…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-11 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 a resident's palm protector, per his functional maintenance program, for 1 of 1 resident reviewed for limited range of motion. (Resident V) Findings include: The clinical record for Resident V was reviewed on 2/6/26 at 12:00 p.m. The resident's diagnosis included, but was not limited to: contractures (a permanent or long-term tightening, shortening, and hardening of muscles, tendons, ligaments, or skin, causing joint deformity and reduced, painful range of motion). An observation of Resident V was made in his room on 2/5/26 at 3:00 p.m. He was sitting in his wheelchair in his room and his left hand was contracted. The resident had no splint, carrot, or pal protector in place. There were no physician's orders for a splint, carrot, or palm protector for the resident's left hand. The ADL care plan, revised 8/26/25, indicated the resident needed total assistance with his activities of daily living. The interventions were for staff to encourage him to wear his left-hand palm protector for up to 4 to 8…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-11 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to timely implement provision of a resident's nutritional supplements for 1 of 1 resident reviewed for nutrition. (Resident 25) Findings include:The clinical record for Resident 25 was reviewed on 2/6/26 at 12:30 p.m. Her diagnosis included, but was not limited to, dementia (mental decline). An interview was conducted with Family Member 2 on 2/6/26 at 12:38 p.m. The family member indicated Resident 25 hadn't been eating very well lately and had lost weight. The weights in the vitals section of the electronic health record indicated the resident had the following weights on the following dates: -On 1/12/26, the resident weighed 145.8 pounds-On 1/22/26, the resident weighed 149.8 pounds-On 1/26/26, the resident weighed 150 pounds-On 2/01/26, the resident weighed 142.8 pounds-On 2/02/26, the resident weighed 142.4 pounds The nutrition care plan, revised on 1/13/26, indicated the resident's intervention was for her to receive her diet, as ordered. The…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-22 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure a resident was treated with dignity and respect for 1 of 4 residents reviewed for dignity. (Resident B)Findings include: The clinical record for Resident B was reviewed on 8/21/25 at 12:10 p.m. The diagnoses included, but were not limited to, depression and pain in the right knee. A Quarterly Minimum Data Set assessment, completed 8/5/25, indicated he was moderately cognitively impaired and had severe signs and symptoms of depression.A Psychological Progress Note, dated 8/12/25, indicated he was oriented to person, place, and had mild impairment in thought process. On 8/21/25 at 12:40 p.m., Resident B was observed in his room. He was sitting in his wheelchair by his bed, and the room door was closed. Certified Nurse Aide (CNA) 2 opened the door without knocking. CNA 2 asked Resident B if he was okay and if he had his call light. Resident B responded that he was fine. CNA 2 exited the room, closing the door behind her. Resident B indicated the staff come into his room often without knocking and it…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-28 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately 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 timely notify a resident's representative of a medication change for 1 of 3 residents reviewed for changes of condition. (Resident C) Findings include: The clinical record for Resident C was reviewed on 5/27/25 at 10:55 a.m. The diagnoses included, but were not limited to, dementia and rheumatoid arthritis. A Quarterly Minimum Data Set (MDS) assessment, completed 4/9/25, indicated Resident C was cognitively intact. A progress note, dated 1/15/25, indicated nursing staff had reported increased confusion and lethargy since taking Baclofen (a muscle relaxant) 10 milligrams (mg). Due to the resident's fatigue, there was a concern for the use of multiple medications at the same time, and several medications were discontinued, including Baclofen. A progress note, dated 5/6/25, indicated Resident C was experiencing chronic muscle spasms and was taking Tizanidine (medication used to treat muscle spasms) to manage her pain. The resident continued to experience muscle spasms and pain despite the use of the medication. Due to the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-28 · tag F0628 — isolated
    Provide 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 document the reason for transferring a resident to a local hospital and ensured communication to the receiving health facility for 1 of 3 residents reviewed for discharge rights. (Resident B) Findings include: The clinical record for Resident B was reviewed on 5/27/25 at 10:30 a.m. The diagnoses included, but were not limited to, multiple sclerosis and hypertension. A care plan, last revised on 4/15/25, indicated Resident B's plan was to discharge home with her spouse. The goal was for her to be discharged home. The interventions included, but were not limited to, arrange for and set up community resources and to educate her on her clinical condition and medications as needed. A Medicare Part A Discharge Minimum Data Set (MDS) assessment, completed 5/5/25, indicated Resident B's Medicare Part A payment coverage ended on 5/5/25. A physician's order, dated 5/5/25, indicated Resident B was to be evaluated and treated by hospice services. A physician's order, dated 5/5/25, indicated she was not to be resuscitated (DNR). 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · D2025-03-12 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    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 1 of 3 residents reviewed for pressure ulcers had a baseline care plan developed and implemented within 48 hours of admission. (Resident D) Findings include: The clinical record of Resident D was reviewed on 3-12-25 at 9:25 a.m. His diagnoses included, but were not limited to metabolic encephalopathy, atherosclerotic heart disease, high blood pressure and cognitive impairment following cerebrovascular disease. His admission Minimum Data Set (MDS) assessment, dated 2-26-25, indicated he had severe cognitive impairment and was admitted with a stage 2 pressure ulcer. A review of his admission nursing assessment, dated 2-21-25, indicated he was admitted to the facility with a pressure ulcer to the coccyx. A review of Resident D's care plans indicated there was not a baseline care plan developed for Resident D related to skin concerns or pressure ulcers. In an interview with the Wound Nurse on 3-12-25 at 1:05 p.m., she indicated she and the MDS staff were responsible for developing care plans for any skin related issues.…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-12 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure 1 of 3 residents reviewed for pressure ulcers had a comprehensive care plan developed and implemented. (Resident D) Findings include: The clinical record of Resident D was reviewed on 3-12-25 at 9:25 a.m. His diagnoses included, but were not limited to metabolic encephalopathy, atherosclerotic heart disease, high blood pressure and cognitive impairment following cerebrovascular disease. His admission Minimum Data Set (MDS) assessment, dated 2-26-25, indicated he had severe cognitive impairment and was admitted to the facility with a stage 2 pressure ulcer. A review of his admission nursing assessment, dated 2-21-25, indicated he was admitted to the facility with a pressure ulcer to the coccyx. A review of Resident D's care plans indicated there was not any type of care plan developed for Resident D related to skin concerns or pressure ulcers. In an interview with the Wound Nurse on 3-12-25 at 1:05 p.m., she indicated she and the MDS staff were responsible for developing care plans for any skin related issues. In 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-01-15 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure residents were treated with dignity and respect for 5 of 6 residents reviewed for dignity. (Residents' 13, 24, 37, 43, and 95) Findings include: 1. A resident council meeting was conducted on 1/09/25 at 11:05 a.m. The resident attendees in the meeting were the following: Residents' 13, 16, 17, 33, 34, 39, 43, 55, 65, 79, 85, and 94. During the meeting the resident council indicated the staff do not respect and/or maintain the residents' dignity. The staff need sensitivity training. They do not have any compassion for the residents. The staff were rude with bad attitudes and disrespectful. During sleeping hours, the staff speak to one another in loud voices along with laughing and yelling down the hallway. The residents overhear inappropriate comments made by the staff as the following, I don't want to work on 200 hall. I don't get paid enough for this. I only get 20 minutes per resident to assist with getting residents up, so no I don't have time to wash your hair. I am the only one here. The staff turn off call…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-15 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care plan meetings were conducted quarterly for 2 of 2 residents reviewed for care plan meetings (Resident 63 and Resident 95). Findings include: 1. The clinical record for Resident 63 was reviewed on 1/9/25 at 2:46 p.m. The diagnosis included, but were not limited to, depression and hypertension. An Annual Minimum Data Set (MDS) assessment, completed 10/25/24, indicated he was cognitively intact. The clinical record contained a Multidisciplinary Care Conference Summary, dated 2/26/23. A Social Services Assessment, dated 11/19/24, indicated that Resident 63 was invited to his scheduled care plan meeting. During an interview on 1/9/25 at 2:46 p.m., Resident 63 indicated that he was unsure of the last time he was invited to a care plan meeting, it may have been over a year ago. During an interview on 01/14/25 at 10:42 a.m., the Social Service Director (SSD) indicated a care plan meeting was held on 2/14/24 and 11/19/24. There were no other care…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-15 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide routine oral care and appropriate incontinence care timely to 1 of 5 residents reviewed for Activities of Daily Living (ADL) care (Resident B). Findings include: The clinical record for Resident B was reviewed on 01/10/25 at 1:35 p.m. The diagnoses included, but were not limited to, hemiplegia (a condition causing paralysis or weakness on one side of the body) secondary to a CVA (cerebral vascular accident). A Quarterly Minimum Data Set (MDS) assessment, completed 10/25/24, indicated he was cognitively intact, had impairment on one side of the upper extremity, required supervision or touching assistance from staff with oral care, and required substantial/maximal assistance with toileting hygiene. A care plan, created on 02/06/24, indicated Resident B had a problem with oral health related to carious (decayed), and missing teeth. The goal was his oral health will not decline. The interventions, created on 02/06/24, were to assist him with oral care two times a day with a.m. and p.m. care. He was to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-15 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide 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 ensure pre and post assessments were conducted for a resident receiving dialysis for 1 of 1 resident reviewed for dialysis. (Resident 43) Findings include: The clinical record for Resident 43 was reviewed on 1/9/25 at 1:55 p.m. The diagnoses included, but were not limited to, end stage renal disease. A dialysis care plan, dated 10/25/24, indicated I [Resident 43] have end stage kidney disease requiring dialysis. I no longer have any urinary output. I have a fistula in my left arm. The goal was to remain free of infection through the next review utilizing my care plan interventions. The interventions included I will report and you will observe for side effects of dialysis such as change in level of consciousness, cramping, fatigue, headaches, itching, and bleeding . A physician order, dated 12/31/21, indicated the resident received dialysis Mondays, Wednesdays, and Fridays at 10:30 a.m. The November 2024, December 2024, and January 2025 pre and post dialysis assessments for Resident 43 were reviewed. The following day(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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-12-05 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure residents' respect and dignity was maintained by staff not being respectful and ensuring a resident was able to exercise her right to vote for 1 of 23 residents reviewed for activities and 26 of 104 residents reviewed for dignity. (Residents' B, C, D, E, F, G, H, J, K, L, M, N, P, Q, R, S, T, V, W, X, Y, Z, BB, CC, DD, EE, and FF) Findings include: 1a. A resident council meeting was conducted on 11/28/23 at 2:30 p.m. The residents that attended the meeting was the following: B, C, D, E, F, G, J, K, L, M, N, P, Q, R, S, T, V, W, X, Y, Z, BB, and CC. During the meeting, the council indicated they do not feel the staff are respectful. Some staff use foul language and are on their personal cell phones during care. They do not respond to the call lights timely. The staff will come into the residents' rooms turn off their call lights and then immediately leave the room without providing the service that was needed. 1b. A Quarterly Minimum Data Set (MDS) assessment, dated 10/2/23, indicated Resident FF was cognitively…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-12-05 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to follow up with resolutions to grievances reported in resident council for 3 of 3 resident council minutes reviewed. (Residents' B, C, D, E, F, G, J, K, L, M, N, P, Q, R, S, T, V, W, X, Y, Z, BB, and CC) Findings include: The September 2023, October 2023, and November 2023 Resident Council Minutes were provided by the Executive Director on 11/28/23 at 1:10 p.m. The minutes indicated the following grievances discussed: September 2023 Resident Council Minutes: A resident stated she wanted her name removed from the scheduled exercise class on the activity's calendar. A resident had not received her prizes she won from bingo activity. October 2023 Resident Council Minutes: Old business: Nursing: Staff talking about residents in the hallway and the conversations are overheard by residents. Activities: Residents want their winnings after playing bingo. Kitchen: Residents requesting breakfast for dinner Housekeeping: Request for staff utilize bleach to clean rooms. New business: Nursing: Certified Nursing Aides (CNA)s leave…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-05 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a resident had a care plan to address his seizure diagnosis for 1 of 5 residents reviewed for unnecessary. (Resident 74) Findings include: The clinical record for Resident 74 was reviewed on 11/30/23 at 9:55 a.m. His diagnoses included, but were not limited to: bilateral above knee amputation, type 2 diabetes mellitus, and congestive heart failure. The 9/21/23 Quarterly MDS (Minimum Data Set) Assessment indicated he had a BIMS (brief interview for mental status score) of 15, indicating he was cognitively intact. An interview was conducted with Resident 74 on 11/30/23 at 10:00 a.m. He indicated he went to the hospital because he had a seizure. The seizure was a few days after falling backwards in his wheel chair and hitting his head. He was now taking medication to address his seizures and hadn't had any since. The 9/5/23 hospital notes read, .presented on 9/5/2023 c/o [complaints of Seizures (Seizure today during rehab [rehabilitation]at ECF [extended care facility,] EMS [emergency medical services] report postictal…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-05 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's care plan included non-pharmacological interventions for pain management and ensure care plan meetings were completed quarterly and when a resident had a significant change for 3 of 24 residents' care plans reviewed. (Residents' 30, 57 and G) Findings include: 1. The clinical record for Resident 30 was reviewed on 11/29/23. Resident 30's diagnoses included, but not limited to, diabetes type II, pain in right shoulder, pain in left shoulder, generalized muscle weakness, and other reduced mobility. During a resident council meeting held on 11/28/23 at 2:11 p.m., Resident 30 indicated, she can't always make it down to the activity room for activities related to her pain. An interview with Resident 30 conducted on 11/29/23 at 9:56 a.m. indicated, she has arthritis pain and requested for her physician to increase her dose of pain medication however, the physician had explained she was on a high dose of pain medication already. Resident…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-05 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to: administer a resident's morning medications timely for 1 of 3 residents reviewed for ADLs (Activities of Daily Living) (Resident EE); adequately document a resident's behaviors per the facility's behavior documentation policy for 1 of 5 residents reviewed for unnecessary medications (Resident EE); ensure a resident's pain was managed per the facility's pain management policy; coordinate care for a resident on hospice services (Resident 57) for 1 of 1 residents reviewed for hospice; and perform neurochecks following a resident's unwitnessed fall with head injury (Resident 57) for 1 of 3 residents reviewed for accidents. Findings include: 1. The clinical record for Resident EE was reviewed on 11/30/23 at 2:28 p.m. Resident EE's diagnoses included, but not limited to, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), diabetes type II, depression, anxiety, and chronic kidney disease. An interview with Resident EE conducted on 12/1/23 at 10:35 a.m. indicated, she had not received her…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to timely implement a resident's fall intervention; update a resident's care plan with identified safety interventions to prevent accidents; and appropriately implement a safety intervention to prevent accidents for 2 of 3 residents reviewed for accidents. (Residents 74 and L) Findings include: 1. The clinical record for Resident 74 was reviewed on 11/30/23 at 9:55 a.m. His diagnoses included, but were not limited to: bilateral above knee amputation, type 2 diabetes mellitus, and congestive heart failure. The at risk for falls care plan, revised 10/11/23, indicated he was at risk for falls related to him being a bilateral amputee and a history of falling. The 9/21/23 Quarterly MDS (Minimum Data Set) Assessment indicated he had a BIMS (brief interview for mental status score) of 15, indicating he was cognitively intact. An interview was conducted with Resident 74 on 11/30/23 at 10:00 a.m. He indicated he fell backwards in his wheel chair twice, and hit his head, because he didn't have any anti-tippers (optional…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-05 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide 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 check assess a dialysis fistula as ordered by the physician and to complete post dialysis assessments timely for 1 of 1 resident reviewed for dialysis (Resident 36). Findings include: The clinical record for Resident 36 was reviewed on 12/1/23 at 2:10 p.m. The Resident's diagnosis included, but were not limited to, chronic kidney disease and anemia. A care plan, last revised 8/12/22, indicated Resident 36 had end stage kidney disease and required dialysis. The goal was for him to remain free from infection, The approaches included that he would attend dialysis on scheduled days and times, initiated 10/20/23, and that his AV (connection of artery and vein) fistula was in his left upper arm, initiated 10/20/23. A physician's order, dated 1/18/23, indicated the check the bruit (sound of blood flow) and thrill (vibration felt) of dialysis fistula every shift. A physician's order, dated 2/21/23, indicated he was to receive hemodialysis on Monday, Wednesday, and Friday. A Quarterly MDS (Minimum Data Set) Assessment, completed…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-05 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications stored in the facility's medication carts were not expired and/or had current orders for their use and vacu-tainers used for blood collection were not expired for 2 of 4 medication rooms and 4 of 8 medication carts reviewed. Findings include: 1. An observation of a medication cart on the 400 hallway with LPN (Licensed Practical Nurse) 3 was conducted on [DATE] at 11:13 a.m. Inside the medication cart was a bottle of Tylenol 325 mg tablets for Resident 62. The bottle of Tylenol tablets indicated, the expiration date was [DATE]. An interview with LPN 3 conducted at the same time as the observation, indicated, the expired medication should have been removed from the medication cart. 2. An observation of a medication cart on the 100 hallway with LPN 10 was conducted on [DATE] at 11:50 a.m. Inside the medication cart was a bottle of Chloroseptic throat spray 1.4% for Resident 49. A review of Resident 49's current 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to TLC MANAGEMENT — 20 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 53.8-0.8 vs chain
Health inspection 2 of 53.3-1.3 vs chain
Staffing 4 of 53.5+0.5 vs chain
Quality measures 5 of 54.7+0.3 vs chain
The other 19 homes this chain runs (chain average 3.8★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
RIVERVIEW HOSPITALOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 08/01/2017
FRIEND, JAYNAIndividualCORPORATE OFFICERsince 06/01/2021
HYATT, DAVIDIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 08/01/2017
BRIARWOOD HEALTHCARE OPERATIONS COMPANY, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/16/2025
TENDER LOVING CARE MANAGEMENT INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/16/2025
DAWSON, STACIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2017
YASSIN KASSAB, MAHMOUDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2017
GIBSON, CULLENIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/16/2025
OTT, BRADLEYIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/16/2025
OTT, DWIGHTIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/16/2025
OTT, GARYIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/16/2025
OTT, RYANIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/16/2025
SHOWALTER, JENNIFERIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/16/2025
DWIGHT A. OTT AND GLORIA OTTOrganizationTRUSTEE OF THE SNFsince 08/01/2017
OTT FAMILY TRUSTOrganizationTRUSTEE OF THE SNFsince 08/01/2017
INDIANAPOLIS HEALTH CARE MANAGEMENT, INC.OrganizationADP OF THE SNFsince 08/01/2012

CMS files one row per role, so the 21 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted.

6 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.

$17.2M
Net patient revenuemost recent cost report
+7.7%
Operating marginrevenue minus expenses
$3.6M
Related-party expense23% of expenses
Who pays — share of resident-days
Medicaid 0%Medicare 6%Other / private 94%

This home reported $3.6M paid to related parties — landlords or management companies under common ownership — equal to about 23% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$396per resident / day
operating cost
$12,036per month
≈ monthly operating cost
$429per day
avg. revenue, all payers

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

What families pay in IN

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 155628. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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