No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Majestic Care Of Southport

8549 S Madison Ave, Indianapolis, IN 46227 · For profit - Corporation · 122 certified beds · (317) 881-9164 Medicare & Medicaid certified

Call the home — (317) 881-9164 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Feb 2025
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (20) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (60%) runs well above the national median (45%)

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

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

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 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

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
8725 S US 31 · (317) 881-6708 · Call to confirm hours
Pharmacy
1635 E Southport Rd · (317) 879-5514 · Call to confirm hours
Grocery
6838 S Madison Ave · (317) 410-1833 · Call to confirm hours
Park
Gray Park0.4 mi
3801 E. Southport · (317) 327-7275 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 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 1 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased0.4%11.0%15.4%better
Long-stay residents who lose too much weight5.6%5.5%5.4%typical
Long-stay residents with a catheter left in their bladder0.0%0.4%0.9%better 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 symptoms20.2%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 injury4.2%3.9%3.3%worse
Long-stay residents whose ability to walk worsened0.0%11.9%16.1%check this — see note marked star below the table
Long-stay residents on antianxiety or hypnotic medication21.7%23.5%18.9%worse
Long-stay residents given the seasonal flu vaccine92.6%95.4%95.3%typical
Long-stay residents with pressure ulcers8.1%3.6%4.7%worse
Long-stay residents with worsening bladder/bowel control28.4%23.3%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table2.4%13.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine23.9%79.0%79.4%worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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.

46.7% 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 25 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

46.7%U.S. median 51.5%
Got home and stayed home
10.8%U.S. median 10.7%
Went back to hospital
0.08U.S. median 0.31
Therapy hours / resident / day
0.02hours / resident / day
Physical therapy
0.05hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.08 therapist hours per resident per day in 2026Q1 — more than 4% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 29% 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 SNF46.7%CMS range 30.6–63.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.8%CMS range 7.3–16.510.7%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were 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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF 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 worsened0.0%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 hospitalization7.8%CMS range 4.4–12.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.991.02Oct 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

0.49
RN hours/ resident / day
0.92
LPN hours/ resident / day
2.18
Aide hours/ resident / day
3.59
Total nurse hours/ resident / day
0.28
RN hoursweekends
59.6%
Total nursing turnover
46.2%
RN turnover

How full it usually is: this home is certified for 122 beds and averages 83.1 residents a day — about 68% occupied, or roughly 39 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.59 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.18 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 3.11 hrs/resident/day on weekends vs 3.78 on weekdays — 18% thinner on weekends. RN hours go from 0.58 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 60% is well above 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

3
deficiencies at the latest standard inspection (2025-09-26)
8
at the previous standard inspection (2024-10-11)

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.

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.

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

  • Potential for harm · Ecited before2025-09-26 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure food was prepared in a sanitary manner for 3 of 3 kitchen observations. Hair was not covered. (Dietary Aide 2) Finding includes: During an observation on 9/22/25 from 8:40 a.m. to 9:00 a.m., Dietary Aide 2 was observed in the kitchen's dishwashing area and food preparation area. Dietary Aide 2 was observed scooping dessert into small bowls for noon meal. Dietary Aide 2 was observed to be lacking hair coverage to the hair on her forehead measuring two inches in length. During an observation on 9/22/25 at 12:37 p.m., Dietary Aide 2 was observed placing food on plates to be served to the residents for the noon meal. Dietary Aide 2 was observed to be lacking hair coverage to the hair on her forehead measuring two inches in length. During an interview on 9/23/25 at 9:25 a.m., the Executive Director indicated that all staff in the kitchen should have all of their hair covered. During an interview on 9/24/25 at 2:58 p.m., the Executive Director indicated 79 of 83 residents received meals from the kitchen. 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-26 · tag F0659 — isolated
    Provide care by qualified persons according to each resident's written plan of care.
    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 physician prescribed daily weights were taken and recorded by qualified personnel for 1 of 1 resident reviewed for daily weights. (Resident 74)Finding includes: On 9/24/25 at 2:33 p.m., Resident 74's clinical record was reviewed. The diagnoses included, but were not limited to, end stage renal disease (ESRD), dependence on renal dialysis, and heart failure. The admission Minimum Data Set (MDS) assessment, dated 9/1/25, indicated Resident 74 was cognitively intact.Physician orders included, but were not limited to, obtain daily weights, notify MD [medical doctor] if weight gain greater than 3 pounds in a day or 5 pounds in a week. The start date was 8/27/25 and no end date was indicated.On 9/25/25 at 10:50 a.m., the Director of Nursing Services (DNS) provided a copy of Resident 74's September 2025 Medication Administration Record (MAR). A review of the document indicated that nursing personnel had initialed the document which signified Resident 74's daily weights had been obtained from September 1st through the 24th.…

    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 before2025-09-26 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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 record review and interview the facility failed to document treatments that were completed in the residents clinical record for 1 of 3 residents reviewed for skin issues. (Resident B) Finding includes: On 9/26/25 10:37 a.m., the clinical record for Resident B was reviewed. The diagnoses included, but were not limited to, diabetes mellitus and neuropathy. Physician orders, dated August 2025, indicated wound Care-left heel: Apply skin prep every morning and at bedtime. The Medication Administration Record lacked signatures that the treatment was completed on the following dates and times: - August 8, 2025, at bedtime. - August 9, 2025, in the morning. - August 10, 2025, at bedtime. - August 13, 2025, in the morning. - August 15, 2025, in the morning. - August 16, 2025, in the morning and at bedtime. - August 19, 2025, in the morning. During an interview on 9/26/25 at 10:00 a.m., the Director of Nursing Services indicated the treatments were completed. The treatments should have been documented in the resident's clinical record once the treatment was completed. On 9/26/25 at…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-26 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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 a resident's transfer to the emergency department was documented in the medical record for 1 of 3 residents reviewed for documentation. (Resident B) Findings include: During an interview on 2/26/25 at 8:10 a.m., Resident B's daughter indicated, on 2/21/25 at approximately 3:00 p.m., she noticed Resident B was lethargic, so she called 911 to have Resident B sent to the emergency department. The clinical record for Resident B was reviewed on 2/26/25 at 8:20 a.m. The diagnoses included, but were not limited to, bladder cancer, asthma, and chronic atrial fibrillation. A hospital palliative care note, dated 2/23/25 at 2:19 p.m., indicated, on 2/21/25, Resident B presented to the emergency department with altered mental status and was admitted to hospital. During an interview on 2/26/25 at 9:10 a.m., the Director of Nursing indicated the nurse that was caring for Resident B, when she was transferred to the emergency department, should have documented a note in Resident B's record regarding the transfer. On 2/26/25 at…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-17 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to protect a resident's right to be free from verbal and physical abuse when a resident cursed at and spit at another resident for 1 of 3 residents reviewed for abuse. (Resident B, Resident C) Findings include: During an interview on 2/17/25 at 9:20 a.m., Resident B indicated, on 1/22/25 or 1/23/25 at approximately 6:30 p.m., Resident B was with other residents waiting to go outside to smoke. Resident C wheeled up to Resident B and called her a b and then said Resident B knew what the f* Resident C was talking about. Resident B got scared and started wheeling back to her room. Resident C wheeled after her. Resident B was afraid Resident C was going to hit her. Resident B got to her room and Resident C continued to yell and curse at her. LPN 2 came and told Resident C to go to the nursing station. Resident D and Resident E wheeled up to Resident B's room to talk to her. A little while after that, Resident B was sitting near her door talking with Resident D and Resident E when Resident C wheeled up again and called…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-17 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to report an allegation of abuse to the state health department when a resident cursed at and spit at another resident for 1 of 3 residents reviewed for abuse. (Resident B, Resident C) Findings include: During an interview on 2/17/25 at 9:20 a.m., Resident B indicated, on 1/22/25 or 1/23/25 at approximately 6:30 p.m., Resident C called Resident B a b. Then Resident C spit on Resident B. The clinical record for Resident C was reviewed on 2/17/25 at 10:55 a.m. The diagnoses included, but were not limited to, schizophrenia, alcohol abuse, psychoactive substance abuse A Progress Note, dated 1/22/25 at 11:00 p.m., indicated Resident C had become agitated with Resident B. Resident C was argumentative with Resident B. Resident C was redirected to her room then Resident C came back into the hallway and started yelling at Resident B and attempted to spit on Resident B. Resident C was again redirected to her room. Director of Nursing notified. During an interview on 2/17/25 at 11:06 a.m., the Administrator indicated he received a…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-11 · 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 residents were treated with dignity for 1 of 12 residents observed during the noon meal. Staff did not sit to assist residents with their meal. (Resident 60) Finding includes: During a dining observation on 10/7/24 at 12:10 p.m., Unit Manager (UM) 2 assisted Resident 60 with the noon meal while standing over Resident 60. UM 2 was not observed to be seated. During an interview on 10/7/24 at 12:48 p.m., the Director of Nursing (DON) indicated that staff should be sitting at eye level but not standing while assisting residents with meals. During an interview on 10/7/24 at 12:50 p.m., UM 2 indicated staff should be sitting at eye level when assisting residents with meals. On 10/8/24 at 8:50 a.m., Resident 60's clinical record was reviewed. The diagnosis included but was not limited to, Alzheimer's disease. A Quarterly Minimum Data Set (MDS) assessment, dated 9/18/24, indicated the resident had severe cognitive impairment and required extensive assistance with eating. On 10/7/24 at 12:56 p.m., the DON…

    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 · D2024-10-11 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each 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 provide reasonable accommodation of needs for 1 of 4 residents reviewed for environment. Call lights were not within reach. (Resident 8) Findings include: During an observation on 10/7/24 from 11:47 a.m. to 11:55 a.m., Resident 8 was observed resting in bed. Resident 8's call light was observed mounted to the wall between Resident 8's bed and the roommate's bed. The call light cord was attached to the wall mount and the other end of the cord was observed lying on the floor behind Resident 8's headboard. The call light was out of reach of Resident 8. During an interview at that time, Resident 8 indicated she was not able to find her call light. During an interview on 10/7/24 at 11:58 a.m., RN 3 indicated all call lights were to be kept within reach of the resident. During an observation on 10/8/24 from 9:13 a.m. to 9:20 a.m., Resident 8 was observed resting in bed. Resident 8's call light was observed mounted to the wall between Resident 8's bed and the roommate's bed. The call light cord was attached 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 · D2024-10-11 · tag F0623 — isolated
    Provide 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 ensure that written Notice of Transfer and Discharge was provided to the resident and the resident's representative for 1 of 6 residents reviewed for transfers and discharges. (Resident 10) Finding includes: On 10/10/24 at 9:57 a.m., Resident 10's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes, COPD (Chronic Obstructive Pulmonary Disease, a lung disease that makes it difficult to breathe), heart disease, and risk for falls. Resident 10's face sheet identified a family member as the resident's representative. The clinical record's Census tab indicated Resident 10 had been transferred to the hospital emergency department on 5/23/24. A progress note, dated 5/23/24 at 2:52 p.m., indicated [Resident 10] returned from ED [Emergency Department] . The clinical record lacked documentation that the written Notice of Transfer and Discharge was provided to the resident and the resident's representative for the facility-initiated hospital transfer on 5/23/24. During an interview on 10/10/24 at…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-11 · tag F0625 — isolated
    Notify 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure written bed hold notifications were provided to the resident and to the resident's representative for 1 of 6 residents reviewed for transfers. (Resident 10). Finding includes: On 10/10/24 at 1:15 p.m., Resident 10's clinical record was reviewed. The diagnoses included, but were not limited to, COPD (a lung disease that makes it difficult to breathe), heart failure, and type 2 diabetes. The clinical record's census tab indicated Resident 10 had been transferred to the hospital emergency department on 5/23/24. A progress note, dated 5/23/24 at 2:52 p.m., indicated [Resident 10] returned from ED [Emergency Department] . The clinical record lacked documentation that the written bed hold notification was provided to Resident 10 or to the resident's representative for the hospital transfer on 5/23/24. During an interview on 10/10/24 at 1:15 p.m., Unit Manager 2 indicated Resident 10 was transferred to the hospital emergency department on 5/23/24. 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
Show the remaining 10 citations
  • Potential for harm · D2024-10-11 · 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 observation, interview, and record review, the facility failed to develop a comprehensive person centered care plan for a resident who refused care for 1 of 1 residents reviewed for Activities of Daily Living. (Resident 62) Finding includes: On 10/7/24 at 10:16 a.m., observed Resident 62 in his room. The resident was in bed and awake. A strong foul smell was noted inside the room. On 10/8/24 at 10:22 a.m., observed Resident 62 in his room. A strong foul odor was noted in the residents room. On 10/9/24 at 9:00 a.m., observed Resident 62 in his room. A strong foul odor was noted in the resident's room. On 10/7/24 at 11:00 a.m., the clinical record of Resident 62 was reviewed. The diagnosis included but was not limited to, morbid (severe) obesity. A care plan, dated 7/19/24, indicated Resident 62 required assistance with activities of daily living secondary to diagnosis of acute on chronic respiratory failure, heart failure, morbid obesity, decreased mobility. The interventions included, but was not limited to, requires the assistance of one staff. The clinical record lacked 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-11 · 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

    Based on interview and record review, the facility failed to ensure weekly weights were recorded in the clinical record and failed to monitor a resident's weight for significant weight changes for 1 of 3 residents reviewed for nutrition. (Resident 23) Finding includes: On 10/8/24 at 3:14 p.m., Resident 23's clinical record was reviewed. The diagnoses included, but were not limited to, Huntington's Disease, diabetes, dementia, asthma, and abnormal weight loss. The Registered Dietician assessment, dated 8/29/24, indicated Resident 23 had a history of abnormal weight loss and required assistance with meals. The clinical record lacked additional dietician evaluations or dietary notes. Physician orders, dated 9/13/24 with no end date noted, indicated weekly weights. Resident 23's care plan, revised on 10/7/24, indicated Resident 23 had a potential nutritional risk related to abnormal weight loss and malnutrition. The care plan goal included will not exhibit significant weight loss. Interventions initiated on 9/25/24 included weights as ordered/indicated, notify MD [physician] 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-11 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    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 drug disposition records for 2 of 2 records reviewed for discharged residents. (Resident 77, Resident 78) Findings include: 1. On 10/10/24 at 9:45 a.m., the clinical record of Resident 77 was reviewed. The diagnoses included, but were not limited to, COPD (a lung disease that makes it difficult to breathe) and type 2 diabetes. A physician's order summary report of medications, dated for active orders as of 9/1/24, included but were not limited to: - acetaminophen 500 mg (milligrams) for pain, fever, or headache - cholecalciferol (vitamin D3) 1,000 units for vitamin deficiency - insulin glargine subcutaneous solution 20 units injection for diabetes - insulin lispro subcutaneous solution with a sliding scale (dosage varied based on blood sugar at time of administration) for diabetes - metformin hydrochloride 500 mg for diabetes - sertraline hydrochloride 50 mg for depression - sodium chloride 1,000 mg for hyponatremia (low sodium levels) - solifenacin succinate 5 mg for bladder spasm A progress note, dated…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-11 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of 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 ensure a current menu was posted for 1 of 1 meal observed. Posted menus were incorrect. Finding includes: During an observation on 10/7/24 at 12:33 p.m., a posted menu was observed on the entry way of the main dining room. The posted menu indicated it was week 4. The menu indicated today's lunch consisted of turkey, carrots, mashed potatoes, and a roll. On 10/7/24 at 12:45 p.m., observed a menu posted on the wall on the entrance to the B wing. The posted menu indicated it was week 3. The menu indicated today's lunch on 10/7/24 consisted of cheesy ham and macaroni, spinach, corn bread, and pineapple tidbits. On 10/7/24 from 12:33 p.m. until 1:00 p.m., observed the facility staff serving the main dining room trays for the noon meal. The meal received by the residents included, brochette chicken, parmesan noodles, green beans, and a dinner roll. During an interview on 10/7/24 at 12:50 p.m., the Staff Scheduler indicated the posted menu's should reflect what was currently being served. During an interview 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-22 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure allegations of abuse were reported to the State Survey Agency for 2 of 3 allegations of abuse reviewed. (Resident B, Resident C) Findings include: 1. During an interview on 4/17/24 at 9:05 a.m., the Social Service Director indicated on approximately 4/2/24, Resident B made an abuse allegation that a black, female staff member hit him in the back of the head. The facility was not able to substantiate the allegation. During an interview on 4/18/24 at 1:00 p.m., Resident B indicated a staff member smacked the back of his head after they had an argument. Resident B did not know if the staff was a nurse or CNA (Certified Nursing Aide), was not able to provide a physical description, and was not sure of the date nor time. During an interview on 4/18/24 at 1:55 p.m., the Administrator indicated on 4/1/24, Resident B made an allegation that a staff member hit him. The Administrator indicated the facility investigated the allegation but were not able to substantiate the abuse allegation. The abuse allegation should have been…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-22 · tag F0742 — isolated
    Provide 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services for a resident diagnosed with PTSD (Post Traumatic Stress Disorder) for 1 of 3 residents reviewed.(Resident D) Finding includes: During an interview on 4/17/24 at 11:23 a.m. Resident F indicated the facility had a major illegal drug and alcohol problem. Resident D drank alcohol in the facility and supplied other resident with alcohol. Resident F reported this to the Administrator. During an interview on 4/17/24 at 12:06 p.m. Resident G indicated Resident G witnessed Resident D offer alcohol to other residents. Resident G reported this to the Administrator. During an interview on 4/18/24 at 1:55 p.m., the Administrator indicated he was aware of allegations of illegal drug and alcohol use in the facility. He indicated the facility had never caught anyone doing drugs inside the facility. Staff did find a bottle of vodka in Resident D's room. At that time, the Administrator pulled a small clear bottle out of his desk…

    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 before2023-11-17 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure food was served in a sanitary manner for 3 of 3 kitchen observations. Mouse droppings were in the dry storage room under cereal and crackers boxes, hair nets were not properly covering hair. (Dietary Manager, Staff 6 Findings include: On 11/13/23 from 10:20 a.m. to 10:30 a.m., during the initial kitchen tour with the DM (Dietary Manager) the following was observed: - Staff 6 was observed walking throughout the kitchen where food preparation was being performed, with a hair net on top of her head leaving the hair on the back of her head exposed approximately 1 foot of mixed braided hair uncovered. The DM, while on initial tour was also observed with a hair net on top of his head leaving hair on the back of his head approximately 4 inches long not covered. The DM was observed to return to food preparation with his hair uncovered. - In the dry storage room rodent traps were noted to be in place, while one trap under the cereal and crackers boxes had multiple mouse droppings observed. During an interview…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-17 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure an incident of alleged resident physical abuse was reported to the State Survey Agency for 1 of 1 residents reviewed for reporting resident abuse. (Resident 43) Finding includes: During an interview on 11/13/23 at 9:30 a.m., Resident 43 indicated a CNA (Certified Nurse Aide) 4 had recently smacked her in the head. Resident 43 indicated that she had reported the incident to the charge nurse. During an interview on 11/13/23 at 10:00 a.m., the DON (Director of Nursing), indicated the allegation was not reported to the State Survey Agency and that it should have been reported. On 11/13/23 at 2:30 p.m., Resident 43's clinical record was reviewed. The Quarterly Minimum Data Set (MDS) assessment, dated 10/30/23, indicated Resident 43 was cognitively intact. On 11/14/23 at 11:30 a.m., the DON provided a copy of the facility reportable incident and associated investigation. The incident occurred on 11/7/23 at 6:30 p.m. and it was reported to Administrator and DON on 11/8/23 during morning meeting at 9:00 a.m. It was reported…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-17 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure 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 verify placement of an enteral tube prior to administering medications for 1 of 2 enteral tube medication administrations observed. (Resident 58) Findings include: On 11/15/23 at 8:40 a.m., Licensed Practical Nurse (LPN) 2 was observed to administer medication to Resident 58 per enteral tube (jejunostomy feeding tube). LPN 2 was observed to not verify the placement of the enteral tube prior to administering the medication. During an interview, at that time, LPN 2 indicated she was not sure if the placement of the tube needed to be verified. On 11/15/23 at 9:00 a.m., the clinical record of Resident 58 was reviewed. The diagnosis included, but was not limited to, gastrostomy. A quarterly Minimum Data Set (MDS) assessment, dated 10/29/23, indicated Resident 58 was moderately cognitively impaired and required a feeding tube. A Physicians order, initiated 5/26/23, indicated check placement of tube [enteral] prior to administration of medications. A care plan, dated 5/26/23 and current through 11/26/23, 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 · D2023-11-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    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 tracheostomy supplies were kept at the bedside for 1 of 2 residents reviewed for tracheostomy care. (Resident 231) Finding includes: On 11/15/23 at 10:54 a.m., Resident 231's clinical record was reviewed. The diagnoses included, but were not limited, to the following: tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck, a person with a tracheostomy breathes through a tracheostomy tube inserted in the opening), chronic respiratory failure with hypoxia (not enough oxygen in the blood), and nontraumatic intracranial hemorrhage (damage to the blood vessel walls). Physician orders, effective 10/30/23 with no identified end dates, included but were not limited to the following: - Tracheostomy size 7. - Keep a spare tracheostomy of same size and one size smaller at bedside every shift. - Oxygen at 4 liters per minute via tracheostomy collar every shift.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to MAJESTIC CARE — 22 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.5+0.5 vs chain
Health inspection 3 of 52.1+0.9 vs chain
Staffing 1 of 51.7-0.7 vs chain
Quality measures 5 of 54.5+0.5 vs chain
The other 21 homes this chain runs (chain average 2.5★, 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
PULASKI MEMORIAL HOSPITALOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 07/01/2021
SEIB, JOHNIndividualCONTRACTED MANAGING EMPLOYEEsince 07/01/2021
BARRY, THOMASIndividualCORPORATE OFFICERsince 07/01/2021
MALOTT, GREGGIndividualCORPORATE OFFICERsince 07/01/2021

1 organizational owner 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.

$12.1M
Net patient revenuemost recent cost report
+6.7%
Operating marginrevenue minus expenses
$1.7M
Related-party expense15% of expenses
Who pays — share of resident-days
Medicaid 83%Medicare 4%Other / private 13%

About 83% 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 $1.7M paid to related parties — landlords or management companies under common ownership — equal to about 15% 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

$383per resident / day
operating cost
$11,654per month
≈ monthly operating cost
$411per 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 155247. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-26, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

What to do next