Hawthorne Healthcare Center
7465 Madison Ave, Indianapolis, IN 46227 · For profit - Corporation · 88 certified beds · (317) 788-3000 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- 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
- the CMS record shows $12,428 in federal fines (most recent 2025-04-23)
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (2/5)
- about 20% 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.
| 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 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 2.3% | 11.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.6% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 1.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 5.3% | 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 | 3.0% | 3.9% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 6.7% | 11.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 25.2% | 23.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 92.5% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.8% | 3.6% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 26.5% | 23.3% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.0% | 13.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.7% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 64.7% | 79.0% | 79.4% | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.27 therapist hours per resident per day in 2026Q1 — more than 39% 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not 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 stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.19 | 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 88 beds and averages 70.9 residents a day — about 81% occupied, or roughly 17 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.31 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.551 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.16 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 3.17 hrs/resident/day on weekends vs 3.37 on weekdays — 6% thinner on weekends. RN hours go from 0.57 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 56% 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 12 most serious are shown; the remaining 15 are one tap away and print in full.
- Immediate jeopardy · Jcited before2025-04-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide supervision to prevent a cognitively impaired resident who resided on the secured memory care unit from exiting the facility property without staff knowledge. The resident was found approximately 1.5 miles from the facility. (Resident B) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on, 4/13/25 at approximately 1:00 a.m., when the facility failed to provide supervision to a cognitively impaired resident, that resided on the memory care unit, to prevent an elopement. The Administrator, Director of Nursing, and Regional Director of Nursing were notified of the Immediate Jeopardy on 4/22/25 at 12:35 p.m. The Immediate Jeopardy was removed, and the deficient practice corrected, 4/14/24, prior to the start of the survey and was therefore Past Noncompliance. Findings include: On 4/22/25 at 8:48 a.m., the Administrator provided a copy of a facility reportable incident, dated 4/13/25 at 4:45 a.m. A review of the reportable incident indicated Resident B walked out of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2024-06-17 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to prevent significant medication errors when a resident diagnosed with C. diff (Clostridium difficile is a germ that causes inflammation of the colon and can be life threatening.) only received 8 of 39 doses of vancomycin (antibiotic used to treat intestinal infections). (Resident B) Finding included: During an interview, on 6/12/24 at 9:24 a.m. Resident B indicated Resident B had an infection but wasn't sure if he received all of his medications. The clinical record for Resident B was reviewed on 6/13/24 at 10:15 a.m. The diagnoses included, but were not limited to, fracture of right humerus, diabetes, and atrial fibrillation. An admission MDS (Minimum Data Set) assessment, dated 6/3/24, indicated Resident B was cognitively intact and frequently incontinent of bowel. A hospital Discharge summary, dated [DATE], indicated Resident B's primary diagnoses included, but were not limited to, diarrhea secondary to C. diff. Resident B 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.
- Potential for harm · Ecited before2025-12-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 ensure potentially hazardous materials were kept secure behind locked doors to prevent residents' potential access to the materials for 3 of 5 days of the survey. Findings include:1. On 12/1/25 at 8:20 a.m., the following was observed in a room near the front entrance of the facility: A room close to the front entrance, labeled Conference Room on a sign to the right of the door was ajar approximately 4-6 inches wide and unlocked. Inside the conference room on the table was a mostly white 16 ounce red-capped bottle sitting on the table; the label on the bottle indicated it was an Rx [Prescription] Destroyer drug disposal all-purpose formula. The bottle appeared mostly full with sticky residue noted around the cap and top of bottle. On the far side of the room from the door, on the floor near a plastic waste receptacle in a clear plastic bag, were eight more bottles of the same appearance and labeling, all full. The labels on the bottle…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-05 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure residents with enteral feedings physician's orders were followed and equipment was dated for 1 of 1 residents reviewed for enteral feedings. (Resident 6)Finding includes:On 12/1/25 at 10:36 a.m., Resident 6 was observed resting in bed. Next to the bed was a pole with an electronic pump device (kangaroo). Hanging from the pole was a 1000 ml (milliliter) plastic bottle of Osmolite (a type of nutritional supplement) 1.5 cal and was connected to the kangaroo pump but was not connected to Resident 6 at that time. The bottle was observed to be three fourths full of a brown colored liquid. The bottle and tubing was undated. During an interview at that time Resident 6 indicated that he did receive Osmolite 1.5 by G-tube.On 12/1/25 at 11:45 a.m., Resident 6's clinical record was reviewed. The diagnoses included, but were not limited to, intestinal bypass and anastomosis status (the surgical creation of a connection between two tubular structures, like blood vessels or loops of intestine), and noninfective…
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 before2024-11-13 · 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 — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure food was served in a sanitary manner for 3 of 4 kitchen observations. Staff hair was not covered while in the kitchen. (Dietary [NAME] 2) Findings include: On 11/6/24 from 11:20 a.m. to 11:23 a.m., Dietary [NAME] 2 was observed walking near the steam table area, located next to the grill and steamer, where the noon foods were being held. Dietary [NAME] 2 was observed to have facial hair, approximately one-half inch in length, above and below the lips. The facial hair was observed to not be covered. During a follow-up kitchen observation on 11/6/24 from 11:35 a.m. to 11:40 a.m., Dietary [NAME] 2 was observed at the steam table area taking the noon meal starting temperatures and plating the noon meal. Dietary [NAME] 2 was observed to have facial hair, approximately one-half inch in length, above and below the lips. The facial hair was observed to not be covered. On 11/6/24 from 12:12 p.m. to 12:20 p.m., Dietary [NAME] 2 was observed at the steam table plating the noon meal. Dietary [NAME] 2 was then…
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 · D2024-11-13 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 observation, interview, and record review, the facility failed to ensure a comprehensive person-centered care plan was developed for 1 of 2 residents reviewed for catheter care. (Resident 3) Finding includes: On 11/6/24 at 11:20 a.m., Resident 3 was observed resting in bed using his laptop computer. A covered urinary catheter bag was observed hanging on the bed frame. On 11/7/24 at 9:21 a.m., Resident 3 was observed resting in bed using his laptop computer. A covered urinary catheter bag was observed hanging on the bed frame. During an interview at that time, Resident 3 indicated he had the indwelling urinary catheter for about a month. On 11/8/24 at 10:00 a.m., Resident 3's clinical record was reviewed. The diagnosis included, but was not limited to, neuromuscular dysfunction of bladder (a condition that causes bladder control issues due to damage to the nervous system). The Quarterly Minimum Data Set (MDS) assessment, dated 8/27/24, indicated Resident 3 was cognitively intact. Physician's orders included, but were not limited to, indwelling urinary catheter, start date of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-20 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to notify a resident's guardian prior to a transfer for 1 of 3 residents reviewed for transfers requirements. (Resident D) Finding includes: The clinical record for Resident D was reviewed on 8/19/24 at 1:16 p.m. The diagnoses included, but were not limited to, epilepsy, alcohol dependence, and vascular dementia. An Order Appointing Guardian Over Incapacitated Person, dated 2/22/23, indicated a guardian was appointed on 2/22/23. A progress note, dated 7/18/24 at 9:34 a.m., indicated Resident D discharged to another facility. All Resident D's belongings were sent with Resident D. The clinical record lacked documentation the guardian was notified prior to Resident D's discharge. During an interview on 8/20/24 at 10:00 a.m., Corporate Nurse 1 indicated there was no additional documentation regarding Resident D's discharge. During an interview on 8/20/24 at 10:45 a.m., LPN 1 indicated Resident D's guardian should have been notified before he was transferred. On 8/20/24 at 10:27 a.m., Corporate Nurse 1 provided a copy of 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 · D2024-08-20 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 provide a written Notice of Transfer/Discharge to the resident's representative prior to a discharge for 1 of 3 residents reviewed for transfer and discharge requirements. (Resident D) Finding includes: The clinical record for Resident D was reviewed on 8/19/24 at 1:16 p.m. The diagnoses included, but were not limited to, epilepsy, alcohol dependence, and vascular dementia. An Order Appointing Guardian Over Incapacitated Person, dated 2/22/23, indicated a guardian was appointed, on 2/22/23. A progress note, dated 7/18/24 at 9:34 a.m., indicated Resident D discharged to another facility. All Resident D's belongings were sent with Resident D. The clinical record lacked documentation the written Notice of Transfer/Discharge was provided to the resident's representative prior to the discharge. During an interview on 8/20/24 at 10:00 a.m., Corporate Nurse 1 indicated there was no additional documentation regarding Resident D's discharge. On 8/20/24 at 10:27 a.m., Corporate Nurse 1 provided a copy of an undated policy, titled…
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 before2024-08-20 · 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 resident's records were complete and accurate for 2 of 3 residents reviewed. Medications were not documented when administered. (Resident B, Resident C) Finding includes: 1. The clinical record for Resident B was reviewed on 8/19/24 at 10:42 a.m. The diagnoses included, but were not limited to, gastroesophageal reflux disease and dystonia. The physician's orders included, but were not limited to: - Carbidopa-Levodopa (medication used to treat central nervous system disorders) 25/250 mg (milligrams) tablet, give one tablet by mouth every three hours, started on 1/19/24. - Hydrocodone/Acetaminophen (narcotic pain reliever) 5/325 mg tablet, give one tablet by mouth every 6 hours for pain, started on 7/22/24. - Omeprazole (medication used for acid reflux) 20 mg delayed release capsule, give one capsule by mouth in the morning, started on 1/19/24. The August 2024 MAR (Medication Administration Record), dated from 8/17/24 at 12:00 a.m., through 8/17/24 at 9:00 p.m., indicated Resident B did not receive the following…
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 · E2024-08-02 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure resident rights were maintained related to being able to go outside in the facility courtyard unsupervised during non-smoking times for 5 of 5 residents reviewed for resident rights. (Residents F, Resident G, Resident H, Resident J, Resident K) Findings Include: 1. During an interview with Resident K on 8/1/24 at 1:00 p.m., he indicated could only go outside in the courtyard during smoking times. He indicated this changed after there was a fight in the gazebo and the Executive Director would not let anyone go out without supervision. Those residents who got in the fight aren't here anymore so residents should be able to go outside. He stated I don't want to be inside all the time with TV. He wanted to go outside and enjoy the beautiful weather. He indicated if you signed out you could go off the property to smoke. 2. During an interview with Resident F on 8/1/24 at 1:14 p.m., he indicated he had been informed by facility staff he was not allowed to go outside to the courtyard to get fresh air at any time unless he…
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 before2024-08-02 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to notify the state health department of an injury of unknown origin for 1 of 3 residents reviewed for abuse. Staff observed a scrape with swelling and bruising to the nose and left eye but did not know how the injury occurred. (Resident M) Finding included: The clinical record for Resident M was reviewed on 8/1/24 at 1:30 p.m. The diagnoses included, but were not limited to, autistic disorder, intellectual disability, and epilepsy. A Quarterly MDS (Minimum Data Set) assessment, dated 7/13/24, indicated Resident M was severely cognitively impaired. A physician's telephone order, dated 7/24/24, indicated x-ray of nose. The order was discontinued. A physician's verbal order, dated 7/25/24 at approximately 3:00 a.m., indicated x-ray of nose due to swelling, mass, lump. An x-ray result, dated 7/25/24 at 9:45 a.m., indicated exam of nasal bones for nasal pain. There was no fracture, dislocation, nor bony destructive lesion noted. Paranasal air cells demonstrate no specific abnormality. No acute traumatic osseous…
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 · D2024-08-02 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 investigate an injury of unknown origin when a resident was observed to have a scrape on his nose with swelling and bruising on his nose and left eye for 1 of 3 residents reviewed for abuse. (Resident M) Finding includes: The clinical record for Resident M was reviewed, on 8/1/24 1:30 p.m. The diagnoses included, but were not limited to, autistic disorder, intellectual disability, and epilepsy. A quarterly MDS (Minimum Data Set) assessment, dated 7/13/24, indicated Resident M was rarely/never understood. A physician's phone order, dated 7/24/24, indicated x-ray of the nose. A physician's verbal order, dated 7/25/24, indicated x-ray of nose due to swelling, mass, lump. An x-ray result, dated 7/25/24 at 9:45 a.m., indicated exam of nasal bones for nasal pain. There was no fracture, dislocation, nor bony destructive lesion noted. Paranasal air cells demonstrate no specific abnormality. No acute traumatic osseous abnormality. A progress note, dated 7/25/24 at 1:17 p.m., indicated the DON (Director of Nursing)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 15 citations
- Potential for harm · D2024-08-02 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide the written bed hold policy prior to leaving the facility or at any time after for 2 of 3 residents reviewed for transfers and discharges. (Resident D, Resident E) Finding included: 1. The clinical record for Resident D was reviewed on 7/31/24 at 11:40 a.m. The diagnoses included, but were not limited to, end stage renal disease, fistula of intestine, and dysphagia. A quarterly MDS (Minimum Data Set) assessment, dated 4/24/24, indicated Resident D was moderately cognitively impaired. A progress note, dated 7/27/24 at 9:40 p.m., indicated Resident D called 911 and asked to be sent to the hospital. Resident D complained of nausea and vomiting and pain at his port site. The clinical record lacked documentation that the written bed hold policy was provided to the resident at the time of transfer or anytime after. During an interview on 7/31/24 at 3:24 p.m., the DON (Director of Nursing) indicated when Resident D called 911 so he could go to the hospital, the staff should have provided a bed hold policy to Resident D…
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 · D2024-08-02 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure medications were secured and labeled for 1 of 1 medication rooms and 1 of 1 random observations. Controlled substances were not double locked and TPN was not labeled and dated. (Resident P, Resident D) Finding included: 1. During an observation on 8/1/24 at 1:38 p.m., an unlocked medication refrigerator was inside the South Medication Room. Inside the refrigerator, observed a clear plastic bag sitting in a pink bin with other medications. The label on the bag, dated 7/30/24, indicated Resident P with a prescription number, Ativan (a controlled anti-anxiety/anti-seizure medication) 2 mg/ml (milligrams/milliliter), inject 0.5 ml (1 mg) intramuscularly (into the muscle) as needed for seizures. The bag contained 5 capped 1 ml vials of liquid. At that time, QMA 1 indicated the Ativan injections should be locked in the lock box in the refrigerator not laying in the pink bin with the other medications. On 8/1/24 at 9:11 a.m., the Administrator provided a copy of a policy, dated 9/2018, titled Storage of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-17 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to notify the physician when staff found a large knife in the drawer of a resident with a history of suicidal ideations and suicidal attempts for 1 of 3 residents reviewed. (Resident B) Finding includes: During an interview 7/17/24 at 8:19 a.m., CNA 1 indicated, on 7/2/24 at approximately 12:15 a.m., Resident B asked CNA 1 to count some money that she kept in a drawer. When CNA 1 opened the drawer CNA 1 saw a large butcher knife. CNA 1 removed the knife and notified LPN 1 and the DON (Director of Nursing). The DON told CNA 1 to put the knife in the medication room and the DON would take care of it. CNA 1 put the knife in the medication room next to a pink plastic wash basin. On 7/17/24 at 8:32 a.m., during an observation of the medication room a pink plastic wash basin was sitting in a cabinet above the sink. Under the pink basin, observed a large metal knife with a dark handle. The blade on the knife was approximately 10 inches long and approximately 2 inches tall. The clinical record for Resident B 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 before2024-07-17 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of abuse to the state health department for 1 of 3 allegations reviewed. A resident with a history of IV (intravenous) drug use made an allegation that a nurse supplied heroin to the resident. (Resident C) Finding includes: During an interview on [DATE] at 5:22 a.m., Resident C indicated she remembered being sent to the emergency department at night on [DATE]. Resident C was told she required CPR (cardiopulmonary resuscitation) and Narcan (medication used to reverse opioid overdose). Resident C snorted heroin (an opioid schedule 1 controlled substance). Resident C got the heroin from someone at the facility but would not say who she got it from because she already told the Administrator and DON (Director of Nursing). During an interview on [DATE] at 6:27 a.m., the Administrator indicated Resident C required CPR in early July and was sent to the emergency department. The facility believed she had taken illegal drugs that night.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-17 · tag F0742 — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
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 implement a care plans with person-centered interventions for a resident diagnosed with suicidal ideations and a history of trauma and suicide attempts for suicidal ideations and suicide attempts for 1 of 3 residents reviewed. Staff found a large knife in the resident's drawer during care. (Resident B) Finding included: During an interview 7/17/24 at 8:19 a.m., CNA 1 indicated on 7/2/24 at approximately 12:15 a.m., Resident B asked CNA 1 to count some money that she kept in a drawer. When CNA 1 opened the drawer CNA 1 saw a large butcher knife. CNA 1 removed the knife and notified LPN 1 and the DON (Director of Nursing). The DON told CNA 1 to put the knife in the medication room and the DON would take care of it. CNA 1 put the knife in the medication room next to a pink plastic wash basin. On 7/17/24 at 8:32 a.m., during an observation of the medication room a pink plastic wash basin was sitting in a cabinet above the sink. Under the pink basin, observed a large metal knife with a dark handle. The blade on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-17 · tag F0835 — failed to run the facility competently — isolatedAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
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 administration failed to maintain the mental and physical wellbeing of residents for 1 of 3 residents reviewed. An allegation of abuse was made against a nurse but was not reported to the state health department and the nurse was not reported to the police. (Resident C) Finding included: During an interview, on [DATE] at 5:22 a.m. Resident C indicated she remembered being sent to the emergency department at night on [DATE]. Resident C was told she required CPR (cardiopulmonary resuscitation) and Narcan (medication used to reverse opioid overdose). Resident C snorted heroin (an opioid schedule 1 controlled substance). Resident C got the heroin from someone at the facility but would not say who she got it from because she already told the Administrator and DON (Director of Nursing). During an interview on [DATE] at 6:27 a.m., the Administrator indicated Resident C required CPR in early July and was sent to the emergency department. The facility believed she had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-05 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide behavioral health services to maintain residents highest practicable well-being for 2 of 3 residents reviewed. Residents with a known history of resident to resident altercations lacked interventions to prevent aggressive behaviors and a resident with a history of drinking alcohol in the facility did not have a plan for treatment and prevention for a substance use disorder. (Resident B, Resident C) Finding included: 1. During an interview on 7/3/24 at 11:53 a.m., the Activity Director indicated Resident B was outside in the courtyard on his way to smoke. Resident C walked up behind Resident B and threatened Resident B. Resident C said if Resident B didn't get out of Resident C's way he would . and then Resident B stood up. At that time, Resident C lunged at Resident B and they both went down to the ground. Neither resident hit the other. They were separated immediately. The Activity Director was not aware of another time when either 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.
- Potential for harm · Ecited before2024-06-17 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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 accurate and complete documentation on the medication administration record and the treatment administration record for 5 of 5 residents reviewed for medication administration. (Resident B, Resident D, Resident E, Resident F, Resident G) Finding included: 1. During an interview, on 6/12/24 at 9:24 a.m. Resident B indicated Resident B wasn't sure if he received all of his medications. The clinical record for Resident B was reviewed on 6/13/24 at 10:15 a.m. The diagnoses included, but were not limited to, fracture of right humerus, diabetes, and atrial fibrillation. An admission MDS (Minimum Data Set) assessment, dated 6/3/24, indicated Resident B was cognitively intact and frequently incontinent of bowel. The physicians orders included, but were not limited to: - Atorvastatin (medication used to treat high cholesterol) 20 mg (milligram) tablet orally at bedtime, started on 5/30/24 with no end date noted. - Cholecalciferol (vitamin D3 supplement) 25 mcg (microgram) tablet orally once daily for supplement, started on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-06-17 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
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 transmission-based precautions for a resident admitted to the facility diagnosed with C. difficile (Clostridium edificial is a germ that causes inflammation of the colon, can be transmitted by person-to-person contact as well as contact with inanimate objects, and can be life threatening. Clostridium difficile can live outside the body on inanimate objects for several months.) for 1 of 4 residents reviewed for infection control. (Resident B) Finding includes: During an interview on 6/12/24 at 9:24 a.m., Resident B indicated Resident B had an infection but wasn't sure if he received all of his medications. The clinical record for Resident B was reviewed on 6/13/24 at 10:15 a.m. The diagnoses included, but were not limited to, fracture of right humerus, diabetes, and atrial fibrillation. An admission MDS (Minimum Data Set) assessment, dated 6/3/24, indicated Resident B was cognitively intact and frequently incontinent of bowel. 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.
- Potential for harm · D2024-06-17 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice 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 notify hospice when a resident received new physicians orders for intravenous (into the vein) antibiotics. (Resident C) Finding included: During an interview on 6/14/24 at 1:57 p.m., Family member 1 indicated Resident C was on hospice services and was supposed to start an oral antibiotic on 5/24/24. Several day later, on approximately 5/29/24, Family member 1 received a phone call from a nurse at the facility that indicated Resident C had a midline placed (an intravenous catheter inserted into the upper arm, into a vein, and extends to the armpit area) and was started on an intravenous antibiotic. Family member 1 was concerned because he wasn't sure hospice was made aware of that before Resident C's midline was placed and wasn't sure if Resident C received the oral antibiotic. During an interview on 6/17/24 at 11:16 a.m. the Hospice VP (Vice President) indicated Resident C started hospice services due to Fornier's gangrene (an acute necrotic infection of the scrotum, penis, or perineum). When a resident starts hospice…
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 before2024-03-15 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure an allegation of abuse was reported to the Administrator for 1 of 3 allegations of abuse reviewed. (Resident B, Resident C) Finding included: During an interview on 3/14/24 at 1:52 p.m., LPN 1 indicated she did not notice anything out of the ordinary with Resident B during LPN 1's shift, on 3/3/24. LPN 1 did not witness the incident between Resident B and Resident C, but Resident B was being rude and pushing his way through other residents near the door that leads out to the smoking area. LPN 1 did not hear Resident B threaten to kill Resident C, but Resident B had threatened to kill other residents in the past. Multiple people reported this to the DON. During an interview on 3/14/24 at 2:58 p.m., QMA 1 indicated on 3/3/24, Resident C was trying to go outside to smoke and Resident B didn't think Resident C was going fast enough and Resident B bumped into Resident C which started an argument. Resident B told Resident C that Resident B was going to kill Resident C. QMA 1 ran to Resident B and Resident C. LPN 1 told…
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 before2024-02-02 · 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 — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure foods were served in a sanitary and safe manner for 4 of 4 kitchen observations. Staff hair was not covered while in the kitchen food preparation area. (Dietary Staff 2, [NAME] 3, and Dietary Staff 4) Findings include: 1. During the initial kitchen tour with [NAME] 3, on 1/28/24 from 10:15 a.m. to 10:30 a.m., the following was observed: - Dietary Staff 2 was observed walking through out the kitchen area and was washing the breakfast meal dishes. Observed Dietary Staff 2 to have facial hair, approximately 1/2 inch in length, above and below the lip area. The facial hair was observed to not be covered. - [NAME] 3 was observed walking through out the kitchen area. Observed [NAME] 3 to have facial hair, approximately 1/2 inch in length, above and below the lip area. [NAME] 3 also was observed to have hair, approximately 1/4 inch in length, on top of his head. The hair was observed to not be covered. 2. During a follow up kitchen observation, on 1/28/24 from 11:30 a.m. to 11:35 a.m., the following 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 · D2024-02-02 · 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 provide services for residents who required dialysis for 1 of 2 residents reviewed. Dialysis access sites were not monitored. (Resident 49) Findings include: On 1/30/24 at 2:37 p.m., the clinical record of Resident 49 was reviewed. The diagnoses included, but were not limited to, end stage renal disease (ESRD), chronic kidney disease, and dependence on renal dialysis. The Quarterly Minimum Data Set (MDS) assessment, dated 1/16/24, indicated Resident 49 was cognitively intact and was dependent on dialysis. Resident 49's care plan included, but was not limited to: Resident is currently on dialysis therapy related to ESRD, initiated 11/10/23 and current through 4/15/24. The interventions included, but were not limited to, report abnormal findings, evaluate resident following dialysis treatment, report abnormal findings, listen for bruit (the swishing sound heard over the site using a stethoscope) and thrill (the vibration felt by the flow of blood at dialysis site). Resident 49's clinical record lacked documentation regarding…
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 before2024-02-02 · 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 accurately and completely document services provided for 2 of 22 residents reviewed. Catheter care was not documented, medication administration was not documented. Resident B, Resident C Findings include: 1. On 1/29/2024 at 2:50 p.m., the clinical record for Resident B was reviewed. The diagnoses included, but were not limited to, retention of urine and obstructive and reflux uropathy (difficulty passing urine). The Quarterly Minimum Data Set (MDS) assessment, dated 1/26/2024, indicated Resident B was cognitively intact and had an indwelling urinary catheter. Resident B's care plan, dated initiated on 4/10/2023 and current through 4/24/2024, indicated Focus: The resident has indwelling catheter [related to] obstructive uropathy .Interventions/Tasks: provide catheter care every shift and PRN . Physician orders included, but was not limited to, foley [urinary] catheter [a medical device that helps drain urine from the bladder] care every shift and PRN [as needed] with soap and water. Secure straps if applicable, document…
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.
- No harm found · C2024-11-13 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
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 ground next to the kitchen's rear door was free from rubbish and failed to ensure the dumpster sliding side panel door was kept closed when not in use for 2 of 3 observations. Findings include: 1. During the initial facility tour with the Dietary Manager on 11/6/24 at 9:35 a.m., the following was observed: - On the ground just outside the kitchen's rear door was a large cardboard box that had unidentifiable debris inside the uncovered box. On the ground near the box, the following was observed: used cups, rags, and other various unidentifiable debris. - The dumpster container area, located approximately 100 yards from the kitchen's rear door was observed. The dumpster area had 2 large dumpster containers. The east dumpster container had 2 sliding side panel doors. The sliding side panel door on the left side of the dumpster container was observed to not be closed. No staff were visible in the area at that time. 2. During a follow up observation on 11/7/24 at 4:50 p.m., the dumpster area 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.
“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
$12,428 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $12,428 — penalty dated 2025-04-23
- Medicare payment denial — starting 2024-08-27 for 1 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to COMMUNICARE HEALTH — 110 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 | 3.2 | +0.8 vs chain |
| Health inspection | 3 of 5 | 2.7 | +0.3 vs chain |
| Staffing | 2 of 5 | 2.6 | -0.6 vs chain |
| Quality measures | 5 of 5 | 4.5 | +0.5 vs chain |
The other 109 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 109; 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 | Since |
|---|---|---|---|
| BORNE-BAUMAN, CANDICE | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2019 |
| FLUECKIGER, RUSSELL | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 07/01/2012 |
| LEHMAN, SCOTT | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 07/14/2020 |
| MACKLIN, LARRY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 07/01/2012 |
| MCINTIRE, DAVID | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2019 |
| ADAMS COUNTY MEMORIAL HOSPITAL | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 07/01/2012 |
| S MADISON MGT CO., LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2017 |
| BARBOUR, JAKOB | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/20/2022 |
| ODENTHAL, RICHARD | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 09/01/2017 |
| RADADIYA, PRAGNESHKUMAR | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/05/2026 |
| SMITH, SCOTT | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2020 |
| SPRUNGER, KYLE | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2018 |
| WHEELER, DANE | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 07/01/2012 |
| BLUE MANAGEMENT SERVICES LLC | Organization | ADP OF THE SNF | since 12/01/2023 |
| FIRST BANK OF BERNE | Organization | ADP OF THE SNF | since 01/01/2020 |
| OMEGA HEALTHCARE INVESTORS INC | Organization | ADP OF THE SNF | since 09/01/2017 |
| OMG IN MSTR LSCO LLC | Organization | ADP OF THE SNF | since 01/05/2026 |
CMS files one row per role, so the 25 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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.
About 87% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.6M paid to related parties — landlords or management companies under common ownership — equal to about 20% 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
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 155780. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-05, 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.