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Rosewalk Village

1302 N Lesley Ave, Indianapolis, IN 46219 · Government - County · 140 certified beds · (317) 353-8061 Medicare & Medicaid certified

Call the home — (317) 353-8061 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0740)1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$14,901 in federal fines
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • 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 (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $14,901 in federal fines (most recent 2025-11-13)
  • 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 (59%) 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
5430 E. Washington St. · (317) 708-3001 · Call to confirm hours
Pharmacy
5543 E Washington St · (317) 359-8278 · Call to confirm hours
Grocery
5430 E Washington St · (317) 357-9182 · Call to confirm hours
Park
5301 E St Clair St · (317) 327-7176 · 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
Short-stay residentsrehab / post-hospital 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.

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

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 increased2.5%11.0%15.4%better
Long-stay residents who lose too much weight2.1%5.5%5.4%better
Long-stay residents with a catheter left in their bladder0.2%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 symptoms24.1%25.2%6.5%typical for the state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.6%3.9%3.3%better
Long-stay residents whose ability to walk worsened2.6%11.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication18.1%23.5%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%95.4%95.3%typical
Long-stay residents with pressure ulcers1.2%3.6%4.7%better
Long-stay residents with worsening bladder/bowel control23.6%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 medication0.4%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine97.2%79.0%79.4%better
Short-stay residents rehospitalized after admission27.6%22.2%22.6%worse
Short-stay residents with an outpatient ER visit0.0%10.8%12.0%check this — see note marked star below the table

* 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.

50.4% 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 68 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.4%U.S. median 51.5%
Got home and stayed home
9.5%U.S. median 10.7%
Went back to hospital
35.5%U.S. median 56.6%
Met the expected recovery
0.20U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 35.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 31 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.20 therapist hours per resident per day in 2026Q1 — more than 23% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 SNF50.4%CMS range 39.0–60.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.5%CMS range 6.4–13.110.7%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 discharge35.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge29.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge38.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified92.5%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 hospitalization6.4%CMS range 3.6–11.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.021.02Oct 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

0.27
RN hours/ resident / day
1.17
LPN hours/ resident / day
2.24
Aide hours/ resident / day
3.68
Total nurse hours/ resident / day
0.16
RN hoursweekends
58.8%
Total nursing turnover
64.3%
RN turnover

How full it usually is: this home is certified for 140 beds and averages 90.6 residents a day — about 65% occupied, or roughly 49 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 3.68 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.27 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.24 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 3.08 hrs/resident/day on weekends vs 3.92 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.31 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 59% 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

5
deficiencies at the latest standard inspection (2026-03-06)
8
at the previous standard inspection (2025-03-13)

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.

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

  • Immediate jeopardy · Jcited before2025-11-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident with a diagnosis of dementia who was at risk of elopement did not exit the facility unsupervised for 1 of 3 residents reviewed for accidents. (Resident B) Resident B was found in the community, had fallen, and was transported to the hospital for treatment.The immediate jeopardy began, on 10/28/25, when Resident B exited the facility unsupervised and without the staff's knowledge while wearing a wanderguard device (a wearable device used to alert staff when a resident approached restrictive areas/doors). The resident was located approximately 0.6 miles away from the facility. The resident was found lying face down on the ground by a concerned citizen. The resident was transported to the hospital and had sustained a laceration and hematoma to his forehead, preorbital edema (swelling around his eye), an abrasion to his left knee and shoulder, and skin tears to the 4th and 5th digit on his left hand. The Executive Director,…

    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 · Past Non-Compliance
  • Potential for harm · Dcited before2026-03-06 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure staff were implementing the care plan with monitoring and documenting outputs for 1 of 1 resident reviewed for implementation of care plans. (Resident 3) Findings include:The clinical record for Resident 3 was reviewed on 3/2/26 at 11:30 a.m. The diagnosis included, but was not limited to: stroke with left side hemiplegia (loss of function/movement). An a.m. and p.m. assistance and monitoring of Activities of Daily Living care plan, dated 11/9/25, indicated the resident required assistance with elimination. One of the interventions on the care plan included staff documenting the residents urine and bowel outputs every shift. A toileting program care plan, dated 11/14/25, indicated Resident 3 was to be toileted by staff every shift; before and after meal service, upon rising and nightly checks. Resident 3's February 2026 and March 2026 output reports indicated the following days and shifts there were no recorded urine outputs: -On 2/1/26, no output was documented for the resident on day and evening shift,-On 2/2/26…

    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 before2026-03-06 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to timely conduct interdisciplinary care plan meetings for 2 of 2 residents reviewed for hospice and 1 of 2 residents reviewed for care planning (Residents 4, 6, and 9).Findings include: 1 The clinical record for Resident 4 was reviewed on 3/2/26 at 11:24 a.m. The resident's diagnoses included, but were not limited to, diabetes and dementia (mental decline). A Quarterly Minimum Data Set (MDS) Assessment, completed 2/4/26, indicated the resident had severely impaired cognition and received hospice services. Resident 4's clinical record contained a Care Plan Summary observation note, dated 2/4/26, that was not completed. The clinical record did not contain information that an Interdisciplinary Care Plan Meeting had been held after the completion on the Quarterly MDS Assessment. 2. The clinical record for Resident 9 was reviewed on 3/3/26 at 10:15 a.m. The resident's diagnoses included, but were not limited to, stroke (when blood flow to part of the brain was interrupted leading to lasting disability) and diabetes. 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-06 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing 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 ensure a resident received vision services for 1 of 1 residents reviewed for vision services. (Resident 50) Findings include: The clinical record for Resident 50 was reviewed on 3/2/26 at 11:30 a.m. The diagnosis included, but was not limited to, stroke (when blood flow to the brain was interrupted causing cells to die lead to lasting disability). The resident was admitted on [DATE]. A quarterly 1/14/26 Minimum Data Set (MDS) Assessment indicated Resident 50 was moderately cognitively impaired. A vision care plan, dated 10/4/23, indicated Resident 50's vision was impaired. The resident wore eye glasses. The staff were to arrange for eye doctor visits as needed. An ancillary consent, dated 10/6/23, indicated Resident 50 did want eye care. An interview was conducted with Resident 50 on 3/2/26 at 2:34 p.m. She indicated she was suppose to receive a new set of eye glasses. She had been waiting for 3 years and had never received them. She had not been seen…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-06 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure 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

    Based on interview and record review, the facility failed to care plan behaviors and interventions for 1 of 1 resident reviewed for behavior management. (Resident 49) Findings include:The clinical record for Resident 49 was reviewed on 3/5/2026 at 4:00 PM. The medical diagnoses included, but were not limited to, anxiety, depression, and encephalopathy. An annual minimum data set assessment, dated 12/9/2025, indicated Resident 49 was cognitively intact, did not exhibit behaviors, hallucinations, delusions, or refusals of care. A care plan, dated 5/22/2024 and revised on 3/4/2026, indicated Resident 49 would refuse medications and weights. The interventions included, but were not limited to, providing space and educate Resident 49 on possible negative effects of refusing medications and weights. A care plan, dated 2/2/2026 and revised on 3/4/2026, indicated Resident 49 exhibited behaviors of becoming tearful. The interventions included, but were not limited to, provide psychosocial support and redirect as needed. A care plan, initiated 3/2/2026, indicated Resident 49 would become…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-06 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for 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 assistance with scheduling and tracking dental services for 2 of 2 reviewed for dental services. (Resident 7 and Resident 25).Findings include: 1 The clinical record for Resident 7 was reviewed on 3/3/26 at 9:27 a.m. The resident's diagnoses included, but were not limited to, diabetes and hypertension (high blood pressure). A Request for Information from the facility dental provider form, dated 10/3/24, indicated Resident 7 consented to receive dental services. A Concern/Grievance Form, dated 11/11/24, indicated Resident 7 wanted to be seen by dental services. The resident was added the list to be seen by dental services on 11/20/24. A progress note, dated 11/21/24, indicated the dental provider had contacted the facility about an outstanding bill with the provider. Resident 7 had paid a portion of the bill but still had an outstanding balance. The outstanding bill needed to be paid in full before the dental provider would provide services. A Quarterly Minimum Data Set (MDS) Assessment, completed…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-03-13 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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 expired food was disposed of timely with the potential to affect 98 of 98 residents that receive food from the kitchen. (Facility) Findings include: The facility kitchen was observed with Culinary Aide 2 (CA) on 3/9/25 at 9:45 a.m. The inspection of the dry storage was conducted with CA 2. During an interview with CA 2, he indicated the top dates on the boxes were delivery dates and bottom dates were expiration dates. The following food items were observed outdated in the dry storage: One bag of graham cracker crumbs - expired 3/5/25, Eleven bags of sugar free Jell-O - expired 2/26/25, Fourteen bags of pork flavored gravy mix- expired 3/5/25, Six bags of cream soup base- expired 3/6/25, Brownie mix- opened 9/14/24 and expired 11/15/24, Cake mix- expired 8/28/24, Streusel topping- expired 11/8/24, Chocolate chips- expired 1/21/25, Two boxes of assorted Jell-O- expired 2/22/25, Twelve bags of vanilla pudding- expired 3/6/25, Cake mix- expired 2/28/25, Four bags of gravy mix- expired 2/28/25, Nine boxes…

    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 · E2025-03-13 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure infection control was maintained by not ensuring hand hygiene was performed prior to donning gloves, failed to utilize hand hygiene during a medication administration, popping pill medication in bare hands for 3 of 6 residents randomly observed for medication administration, and not donning personal protective equipment (PPE) during bathing and dressing for 1 of 1 resident reviewed for dialysis. (Resident 2, Resident 12, Resident 20, and Resident 24) Findings include: 1. The clinical record for Resident 20 was reviewed on 3/9/25 at 11:31 a.m. The diagnoses included, but were not limited to, diabetes. On 3/9/25 at 11:31 a.m., Licensed Practical Nurse (LPN) 25 was randomly observed performing a blood glucose check for Resident 20. LPN 25 gathered the supplies to conduct the blood glucose check from the medication cart, including a pair of disposable gloves. LPN 25 entered Resident 20's room and informed Resident 20 about the need to obtain a blood glucose check. LPN 25 donned the disposable gloves,…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-13 · 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 interview and record review, the facility failed to ensure residents' dignity was respected for 3 of 4 residents reviewed for abuse. (Residents' J, K, and L) Findings include: 1. The clinical record for Resident K was reviewed on 3/10/25 at 10:00 a.m. The diagnoses included, but were not limited to, heart disease. A Quarterly Minimum Data Set (MDS) assessment, dated 1/8/25, indicated Resident K was cognitively intact. An interview was conducted with Resident K on 3/10/25 at 10:09 a.m. She indicated she had reported Licensed Practical Nurse (LPN) 22 to the Executive Director (ED). He was always hateful and rude towards her. LPN 22 was changing her humidifier for her oxygen, and during that time, the interaction between LPN 22 and Resident K was not respectful. LPN 22 had made rude statements to her and stuck up his middle finger. She had stated to him, you're not my daddy, and he responded, you're not my mama. She expected LPN 22 to apologize to Resident K for being treated that way, but she had not received an apology. LPN 22 no longer worked at the facility. A reportable…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-13 · 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 ensure a call light was in reach for 1 of 1 resident reviewed for call lights (Resident G). Findings include: The clinical record for Resident G was reviewed on 3/11/25 at 10:00 a.m. The diagnoses included, but were not limited to, anemia, cancer, heart failure, diabetes, hemiplegia caused by stroke (weakness on one side of the body), and depression. A Quarterly Minimum Data Set assessment, completed 12/20/24, indicated Resident G's preferred language was Spanish, and she needed an interpreter to communicate with doctors or health staff. It also indicated Resident G was cognitively intact with impairment of her right upper extremity. An observation was conducted of Resident G on 3/12/25 at 9:39 a.m. Resident G was in bed and her call light cord was attached to the wall mount on the wall next to the bed. The cord went behind the resident's bed, and it was hanging in front of the headboard near the ground on the right side of the bed. The call light was out of sight and out of reach of the resident. In an…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to get residents up to a wheelchair and complete regular hair shampooing for 1 of 4 residents reviewed for ADLs (Activities of Daily Living). (Resident G) Findings include: The clinical record for Resident G was reviewed on 3/11/25 at 10:00 a.m. The diagnoses included, but were not limited to, anemia, cancer, heart failure, diabetes, hemiplegia caused by stroke (weakness on one side of the body), and depression. A Quarterly Minimum Data Set assessment, completed 12/20/24, indicated Resident G's preferred language was Spanish, and she needed an interpreter to communicate with doctors or health staff. It also indicated Resident G was cognitively intact with impairment of her right upper extremity. On 3/12/25 at 9:39 a.m., Resident G was observed in her room, lying in bed wearing a hospital gown. The resident's hair was oily, stringy, and tangled in the back. She indicated she had not had a shower, a full bed bath, or her hair shampooed in about 10-12 days. She asked the staff to wash her hair, but they did not.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · D2025-03-13 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure a resident with contractures (abnormal shortening or tightening of muscle tissue the renders the muscle highly resistant to stretching and can lead to permanent disability) received splint application as recommended by therapy staff for 1 of 2 residents reviewed for rehabilitation services. (Resident B) Findings include: The clinical record for Resident B was reviewed on 3/11/25 at 10:25 a.m. The diagnoses included, but were not limited to, hemiplegia (one-sided paralysis) and hemiparesis (one-sided muscle weakness) following cerebral infarction (stroke) affecting left non-dominant side, contracture of left wrist, contracture of left knee, contracture of left hand (fingers), contracture of left elbow, and muscle wasting and atrophy. An admission Minimum Data Set (MDS) assessment, dated 1/10/25, indicated Resident B was cognitively intact, had impairment on one side of the upper and lower extremity, substantial assistance with upper body dressing, and dependent for lower body dressing. An activities 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 · D2025-03-13 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 hold insulin when a blood sugar was below the physician's prescribed perimeters for 1 of 1 randomly observed insulin administration (Resident 20). Findings include: The clinical record for Resident 20 was reviewed on 3/9/25 at 11:31 a.m. The diagnoses included, but were not limited to, diabetes. A care plan, dated 10/21/24, indicated she was at risk for adverse effects of hyperglycemia (high blood sugar), or hypoglycemia (low blood sugar) related to use of glucose lowering medication and diagnosis of diabetes. The goal was for her not to experience symptoms of hyperglycemia or hypoglycemia. The interventions included monitoring blood sugar and administer medications as ordered. A physician's order, dated 12/30/24, indicated she was to receive insulin lispro (fast acting insulin) 12 units three times a day with meals; hold if blood sugar was less than 150 milligrams per deciliter (mg/dL). On 3/9/25 at 11:31 a.m., Licensed Practical Nurse (LPN) 25 was randomly observed administering medications to Resident 20.…

    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 · D2025-03-13 · tag F0847 — isolated
    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a binding arbitration agreement was explained to the resident representative and signed by the resident representative for 2 of 3 residents reviewed for arbitration agreements. (Resident 42 and Resident 88) Findings include: 1. The clinical record for Resident 42 was reviewed on 3/13/25 at 11:09 a.m. The diagnoses included, but were not limited to, dementia, age-related physical debility, hypertension, cognitive communication deficit, muscle weakness, and difficulty in walking. Resident 42 was admitted to the facility on [DATE]. An Order Appointing Temporary Guardian document, file date 10/23/24, indicated a temporary guardian was ordered for Resident 42. The powers of the guardian included, but were not limited to, to consent in writing to the medical or surgical treatment of Resident 42 and to enter into contracts for the admission of Resident 42 to any health care facility reasonably deemed necessary for the safety and well-being of 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-13 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to timely address and follow up on a resident's change of condition; administer a resident his medication for insomnia, as ordered; address a resident's skin condition, per policy; administer treatments, as ordered; and accurately monitor fluid consumption for a resident, as ordered, for 2 of 2 residents reviewed for hospitalization, 1 of 5 residents reviewed for unnecessary medications, 1 of 3 residents reviewed for abuse, and 1 of 4 residents reviewed for skin conditions. (Residents 1, 20, 45, 66, and 104) Findings include: 1. The clinical record for Resident 104 was reviewed on 2/8/24 at 2:42 p.m. The diagnosis for Resident 104 included, but was not limited to, acute kidney disease. A care plan dated 9/20/23 indicated Resident is at risk for abnormal/excessive bleeding due to use of anticoagulant. The approaches included but was not limited to, observe for signs of bleeding: blood in urine/BM [bowel movement], dark tarry stools, blood tinged sputum, excessive bruising, bruise increasing in size, oozing from…

    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 · D2024-02-13 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide showers, as preferred, for 1 of 4 residents reviewed for ADL (Activities of Daily Living) care (Resident 45). Findings include: The clinical record for Resident 45 was reviewed on 2/7/24 at 11:22 a.m. The Resident's diagnosis included, but were not limited to, dermatitis and diabetes. A physician's order, dated 9/21/23, indicated to encourage showers 2 times weekly on Tuesday and Friday and to document any refusals. A Preferences for Customary Routine and Activities Observation, dated 1/15/24, indicated that it was very important to Resident 45 to choose between a tub bath, shower and bed bath. The type of bathing he was used to were showers. A Quarterly MDS (Minimum Data Set) Assessment, completed 1/16/24, indicated that he was cognitively intact and dependent on staff for bathing. A care plan, last reviewed on 1/29/24, indicated that Resident 45 had a self-care deficit related to weakness and decreased mobility. He needed assist with ADLs including bathing, dressing, grooming, personal hygiene,…

    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 · D2024-02-13 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to assess vision status, as instructed in the RAI (Resident Assessment Instrument) manual, while completing the MDS (Minimal Data Set) Assessments for 1 of 3 residents reviewed for vision (Resident 24). Findings include: The clinical record for Resident 24 was reviewed on 2/7/24 at 3:38 p.m. The Resident's diagnosis included, but were not limited to, diabetes and hypertension. An admission MDS (Minimum Data Set) Assessment, completed 6/16/23, indicated that Resident 24 was cognitively intact, had adequate vision, and did not wear glasses. A Consultation Note from an eye surgeon, dated 8/7/23, was provided on 2/12/24 at 4:18 p.m., by the Nurse Consultant. The consultation note indicated that Resident 24 had Combined Senile Cataracts in the right and left eyes. Resident 24 had experienced blurred vision for years and it was bothersome to Resident 24, affecting his ability to watch television and recognize faces from across the room. The plan was that the Cataract on his right eye was causing his decreased vision, but Resident…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-13 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a resident had a care plan to address his insomnia and create a vision careplan for a resident with visual difficulties for 1 of 5 residents reviewed for unnecessary medications and 1 of 4 residents reviewed for vision or hearing services. (Residents 24 and 66) Findings include: 1. The clinical record for Resident 66 was reviewed on 2/8/24 at 10:30 p.m. His diagnoses included, but were not limited to, dementia. The physician's orders indicated to administer one 5 mg tablet of melatonin at bedtime, starting 6/6/22, and half of a 50 mg tablet of trazodone at bedtime, starting 12/20/23. The 1/24/24 psychiatry note indicated to continue the Melatonin 5 mg every evening and the Trazodone 25 mg every evening, both for insomnia. It indicated a dose reduction for either medication was contraindicated due to high risk of symptom escalation. The February, 2024 MAR (medication administration record) indicated the Melatonin was not administered on 2/6/24 and 2/7/24 due to the medication being unavailable. It indicated the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-13 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to invite a resident's representative to her care plan meetings for 1 of 2 residents reviewed for care planning. (Resident 1) Findings include: The clinical record for Resident 1 was reviewed on 2/7/23 at 3:00 p.m. Her diagnoses included, but were not limited to: hypertension, seizures, neuropathy, congestive heart failure, osteoarthritis, and diabetes mellitus. The 11/20/23 Significant Change MDS (Minimum Data Set) assessment indicated she had a BIMS (brief interview for mental status) score of 1, indicating she was severely cognitively impaired. Resident 1's face sheet in her electronic clinical record indicated her emergency contact, durable POA (power of attorney,) and health care representative was Family Member 13. It did not indicate the specific family member relationship between Resident 1 and Family Member 13. An interview was conducted with Family Member 13 on 2/7/24 at 3:15 p.m. He indicated he was not invited to routine care plan meetings by the facility. He received phone calls sometimes from an outside nurse…

    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 before2024-02-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide shampooing, toenail care, shaving, and incontinence care for 3 of 5 residents reviewed for Activities of Daily Living (ADL)s. (Resident 78, 97, and 306) Findings include: 1. The clinical record for Resident 97 was reviewed on 2/7/24 at 2:18 p.m. The diagnosis for Resident 97 included, but was not limited to, acute respiratory failure. The admission [DATE] Minimum Data Set (MDS) assessment indicated Resident 97 was cognitively intact. An ADL care plan dated 11/19/23 indicated the resident required assistance with ADL's. The approaches included but was not limited to, Assist with dressing/ grooming/hygiene as needed. The January 2024 shower sheets indicated the following days shampooing, nail care and shaving was not provided with bathing: 1/2/24, 1/5/24, 1/9/24, 1/12/24, 1/16/24, 1/19/24, 1/23/24, 1/27/24, and 1/30/24 The February 2024 shower sheets indicated on 2/2/24 and 2/6/24 a bed bath was provided. Shampooing, nail care and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-13 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to timely follow through with obtaining hearing aides for 1 of 4 residents reviewed for vision or hearing services. (Resident 66) Findings include: The clinical record for Resident 66 was reviewed on 2/8/24 at 10:30 a.m. His diagnoses included, but were not limited to, dementia. The 10/7/21 communication care plan indicated he had some bilateral hearing loss and wore hearing aids. He received new hearing aids on 3/8/22. The goal was for him to hear and understand communication. An approach was to refer him to the audiologist/speech-language pathologist/speech therapist and follow recommendations, starting 10/7/21. The physician's orders indicated to place his hearing aids in his ears at the beginning of the day and on the charging dock at bedtime, starting 6/27/22. An observation of Resident 66 was made in the dining room on 2/8/24 at 10:43 a.m. He had a hearing aid in his left ear, but not in his right ear. An observation of Resident 66 was made on 2/9/24 at 3:18 p.m. He was sitting at a table in the dining…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure fall interventions were appropriately implemented for a resident that has a history of falling for 1 of 1 residents reviewed for accidents. (Resident 58) Findings include: The clinical record for Resident 58 was reviewed on 2/7/24 at 2:27 p.m. The diagnosis for Resident 58 included, but was not limited to, moderate dementia. The Quarterly 1/24/23 Minimum Data Set (MDS) assessment indicated Resident 58 was moderately impaired. A care plan date 7/24/19 indicated .Resident is at risk for falls related to weakness, decreased mobility and cognitive impairments .She requires assist with transfers, walking/locomotion, toileting and bed mobility. Resident has impaired balance/gait and hx [history] frequent falls, uses w/c [wheelchair] & walker . The approaches included but was not limited to, .assist x 1 (staff person) with transfers .assist x 1 with bathing/grooming . A therapy referral dated 10/13/23 indicated the resident needed services for safe transfers due to falling. An Occupational Therapy discharge…

    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 · D2024-02-13 · tag F0776 — isolated
    Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to timely schedule a mammogram, as ordered by the physician, for 1 of 4 residents reviewed for skin conditions (Resident 43) Findings include: The clinical record for Resident 43 was reviewed on 2/7/24 at 12:15 p.m. The Resident's diagnosis included, but were not limited to, anxiety and hypertension. An admission MDS (Minimum Data Set) Assessment, completed 11/29/23, indicated that she was cognitively intact. A progress note, dated 1/3/24 at 12:16 p.m., indicated that the nurse practitioner had given an order for a diagnostic mammogram. The order had been faxed to an outside provider so that an appointment could be scheduled. During an interview on 2/7/24 at 12:15 p.m., Resident 43 indicated that she had felt a lump in her left breast and had been asking to have a mammogram done for about 4 months. She had not had a mammogram yet and the lump was worrying her. During an interview on 2/8/24 at 3:45 p.m., the Regional Infection Preventionist indicated that the mammogram had not been completed as yet, it had just been scheduled…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-13 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure residents' rooms were in good repair and a call light was functioning as appropriate for 3 of 4 resident rooms were observed during a environmental tour. (Residents' 45, 57 and 71) Findings include: An observation was made of Resident 45's room on 2/7/24 at 11:22 a.m. The wall behind the bed was observed to be marred and scratched. An observation was made of Resident 71's room on 2/7/24 at 2:11 p.m. The resident's wall behind the bed was marred. An observation was made of Resident 57's room on 2/7/24 at 2:48 p.m. The resident's wall by the bed was marred. The resident indicated the wall had been marred and scratched for a few months. He reported the call light has to be pushed multiple times before it will turn on. He has to watch the light on the call light wall mount turn green indicating the call light was on. It does not turn on with one push. At that time, he pushed the call light button three times before the green light turned on. During an environmental tour with the Maintenance Director (MD) and the…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2025-03-13 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure postings of current daily working staff. This had the potential to affect 98 of 98 residents that reside in the facility. Findings include: Random observations were made of the facility on 3/09/25 at 10:35 a.m., 10:44 a.m., and 11:27 a.m. The posting of current daily working staff in the facility was dated 3/07/25. An interview was conducted, on 3/13/25 at 9:42 a.m., with the Nurse Schedule Coordinator (NSC). She indicated she completes the staffing sheets that are posted in the facility daily and leaves them for the night shift nurse to post them first thing the following morning. She indicated the night shift nurse forgot to remove the daily working staffing sheet, dated 3/07/25, and post the current staffing sheet. During an interview with the Executive Director (ED) on 3/13/25 at 10:10 a.m., he indicated the NSC usually posted the current daily working staff sheet. If it is a Saturday, nursing staff may forget to post the sheet. The NSC does come in on the weekends at times to help with supplies, so she will also…

    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.

    Nursing and Physician Services 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

$14,901 in federal fines across 1 penalty.

  • $14,901 — penalty dated 2025-11-13

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 AMERICAN SENIOR COMMUNITIES — 90 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 53.9-0.9 vs chain
Health inspection 3 of 53.4-0.4 vs chain
Staffing 1 of 52.3-1.3 vs chain
Quality measures 5 of 54.7+0.3 vs chain
The other 89 homes this chain runs (chain average 3.9★, per CMS)
1 of 5Valparaiso Care & RehabilitationValparaiso, IN 2 of 5Arbor Grove VillageGreensburg, IN 2 of 5Bethany VillageIndianapolis, IN 2 of 5Columbia Healthcare CenterEvansville, IN 2 of 5Community Nursing And Rehabilitation CenterIndianapolis, IN 2 of 5Eagle Valley MeadowsIndianapolis, IN 2 of 5Harcourt Terrace Nursing And RehabilitationIndianapolis, IN 2 of 5Harrison TerraceIndianapolis, IN 2 of 5Hickory Creek At New CastleNew Castle, IN 2 of 5Maple Park VillageWestfield, IN 2 of 5Park Terrace VillageEvansville, IN 2 of 5Riverside VillageElkhart, IN 2 of 5Trailpoint VillageSouth Bend, IN 2 of 5University Nursing CenterUpland, IN 2 of 5Williamsport Nursing And RehabilitationWilliamsport, IN 3 of 5Allisonville MeadowsFishers, IN 3 of 5American VillageIndianapolis, IN 3 of 5Brownsburg MeadowsBrownsburg, IN 3 of 5Countryside MeadowsAvon, IN 3 of 5East Lake Nursing & Rehabilitation CenterElkhart, IN 3 of 5Hickory Creek At CrawfordsvilleCrawfordsville, IN 3 of 5Hillcrest VillageJeffersonville, IN 3 of 5North Capitol Nursing & Rehabilitation CenterIndianapolis, IN 3 of 5Rosebud VillageRichmond, IN 3 of 5Rosewalk Village At LafayetteLafayette, IN 3 of 5Spring Mill MeadowsIndianapolis, IN 3 of 5Stonebrooke Rehabilitation CenterNew Castle, IN 4 of 5Autumn Ridge Rehabilitation CentreWabash, IN 4 of 5Beech Grove MeadowsBeech Grove, IN 4 of 5Clark Rehabilitation And Skilled Nursing CenterClarksville, IN 4 of 5Clinton GardensClinton, IN 4 of 5Creekside VillageMishawaka, IN 4 of 5Edgewater WoodsAnderson, IN 4 of 5Forest Creek VillageIndianapolis, IN 4 of 5Franklin MeadowsFranklin, IN 4 of 5Heritage House Rehabilitation & Health Care CenterConnersville, IN 4 of 5Hickory Creek At ColumbusColumbus, IN 4 of 5Hickory Creek At MadisonMadison, IN 4 of 5Hickory Creek At PeruPeru, IN 4 of 5Hickory Creek At RochesterRochester, IN

Showing 40 of 89; 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 / managerTypeRoleSince
OHI ASSET (IN) ROSEWALK, LLCOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 08/31/2012
CHIES, STEVENIndividualMANAGING CONTROL - GOVERNING BODYsince 03/17/2016
JACKSON, BLAKEIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2003
JACKSON, ETHANIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2003
JACKSON, MARKIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2003
JACKSON, MICHAELIndividualMANAGING CONTROL - GOVERNING BODYsince 05/14/2024
JACKSON, WESSLEYIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2003
JUSTICE, DAVIDIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2003
KELSEY, DONNAIndividualMANAGING CONTROL - GOVERNING BODYsince 07/18/2024
STITLE, STEPHENIndividualMANAGING CONTROL - GOVERNING BODYsince 03/16/2016
WRIGHT, THERESSAIndividualMANAGING CONTROL - GOVERNING BODYsince 05/21/2021
DOUCET, KELLYIndividualCORPORATE DIRECTORsince 02/03/2025
DRUMMER, CARLIndividualCORPORATE DIRECTORsince 01/01/2017
FISCH, GARYIndividualCORPORATE DIRECTORsince 01/01/2025
HANIFY, THOMASIndividualCORPORATE DIRECTORsince 01/01/2022
HORN, BRENDAIndividualCORPORATE DIRECTORsince 09/20/2023
LAZARD, ROBERTIndividualCORPORATE DIRECTORsince 01/29/2021
O'BRIEN, MICHAELIndividualCORPORATE DIRECTORsince 02/03/2025
BABCOCK, PAULIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 09/30/2020
CAINE, VIRGINIAIndividualCORPORATE OFFICERsince 01/10/1994
GODDARD, NICHOLEIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 07/11/2022
HARRIS, LISAIndividualCORPORATE OFFICERsince 12/22/2003
SIMPSON, JAMESIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 08/06/2023
AMERICAN SENIOR COMMUNITIES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2003
THE HEALTH AND HOSPITAL CORPORATION OF MARION COUNTYOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2003
DICE, MARKIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2023
HAFIDH, SAADIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/22/2026
JOHNSON, OMARIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/27/2020
SHANE, ANDREWIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2023
TARUWINGA, LOICEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/03/2023
VAN CAMP, STEVENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2023

CMS files one row per role, so the 41 rows in the source record cover these 31 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.

3 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.

$11.5M
Net patient revenuemost recent cost report
-9.3%
Operating marginrevenue minus expenses
$1.0M
Related-party expense8% of expenses
Who pays — share of resident-days
Medicaid 83%Medicare 4%Other / private 14%

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 $1.0M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$345per resident / day
operating cost
$10,500per month
≈ monthly operating cost
$316per 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 155329. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-06, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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