Washington Healthcare Center
8201 W Washington St, Indianapolis, IN 46231 · Government - County · 94 certified beds · (317) 244-6848 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- it has a citation for mishandling residents’ money or property (F0565)
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 4.3% | 11.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.0% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 1.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 21.9% | 25.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.0% | 3.9% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 3.5% | 11.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 19.3% | 23.5% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 89.3% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.2% | 3.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 21.4% | 23.3% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.3% | 13.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 4.0% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 52.5% | 79.0% | 79.4% | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
58.1% 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 42 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.18 therapist hours per resident per day in 2026Q1 — more than 17% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 58.1%CMS range 42.0–74.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.6%CMS range 6.2–15.9 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.99 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 94 beds and averages 61.3 residents a day — about 65% occupied, or roughly 33 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 3.40 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.09 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 3.21 hrs/resident/day on weekends vs 3.48 on weekdays — 8% thinner on weekends. RN hours go from 0.64 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
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 before2023-05-26 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY A. Based on observations, interviews and record review, the facility failed to ensure non-pressure wounds on a resident's toes were treated in a timely manner and failed to follow up on an arterial doppler causing a delay in treatment of the wounds which resulted in osteomyelitis, gangrene, and cellulitis for 1 of 3 reviewed for quality of care (Resident 45). B. Based on observation, interview, and record review, the facility failed to ensure residents had appropriate skin assessments and interventions in place to address non-pressure wounds for 2 of 3 residents reviewed for skin management (Residents 31 and 21). The immediate jeopardy began on 4/25/23 when Resident 45 was noted to have developed new wounds on his left and right toes. No treatments were ordered until 4/27/23. The wound doctor observed the wounds on 4/28/23 and diagnosed the resident with osteomyelitis. A bilateral doppler ultrasound was ordered on 4/28/23 and completed on 5/1/23. However, the facility failed to follow up in a timely manner to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-08-12 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable, and homelike environment for 7 of 7 residents who had observed concerns (Residents 40, 10, 12, 5, 47, 20, and 51).Findings include:1. On 8/6/25 at 10:10 a.m., Resident 40's call light was observed out of reach, wrapped on top of the bedside dresser. The cord was visibly dirty with stains and built-up debris under peeling tape. On 8/8/25 at 10:00 a.m., Resident 40's call light remained out of reach, hung over the call box on the wall. The cord remained dirty. On 8/11/25 at 9:31 a.m., Resident 40's call light was observed hung out of reach on the call box, the cord remained dirty. On 8/12/25 at 10:25 a.m., Resident 40's call light remained out of reach and rested on the floor. The yellow tape was still peeling and there was stuck on debris. There were several gnats flying around his head and in the bathroom. 2. On 8/6/25 at 10:29 a.m., Resident 10's fall mattress on the floor beside his bed was observed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to ensure proper oral hygiene was provided and maintained for a dependent resident (Resident 5) and failed to ensure a resident preference for facial hair was maintained (Resident 49) for 2 of 4 residents reviewed for Activities of Daily Living.Findings include:1.On 8/6/25 at 10:49 a.m., Resident 5 was observed. She laid in her bed and had a Tube Feeding hung and running. Her lips were dry and cracked, there was a pasty/frosty build-up around her lips and gums. On 8/6/25 at 12:02 p.m., Resident 5's was observed. Her lips remained dry and cracked, and there was a thick build-up of pasty drying secretions. There was an uncovered cup of blue liquid and an oral sponge left on her bedside table. There were two gnats on the rim of the cup. On 8/7/25 at 9:09 a.m., Resident 5 was observed. Her lips were dry and cracked, and a thick layer of pasty secretions rimmed her lips and gums. Her teeth were also observed to have built up plaque/tarter. On 8/8/25 at 10:17 AM Resident 5 was observed. Her mouth remained in need of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-12 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide appropriate, person centered programing, and treatment plans to attain or maintain the highest practical level of psychosocial well-being for 1 of 5 residents (Resident 11) reviewed for behavioral health concerns.Findings include:On 8/6/25 at 10:50 a.m. Resident 11 was observed as she lay in bed watching her roommate's tv and resting. There was no tv on her side of the room. Resident 11 indicated she arrived at the facility about 5 months ago and hadn't had any problems so far. She appeared to have a flat affect (a severe reduction in the outward expression of emotion) and a low mood.On 8/7/25 at 9:45 a.m. the memory care unit dining room was observed. There were three residents at a table with the Dementia Care Facilitator watching a cooking show on a tablet and two residents sitting on the couch watching TV. This was not the scheduled activity.On 8/7/25 at 12:01 p.m. Resident 11 was observed in bed resting with her eyes…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-12 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
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 vegetarian resident had food variety and options to meet his dietary preferences for 1of 1 resident reviewed for dietary preferences (Resident 43). Findings include:On 8/6/25 at 11:00 a.m. Resident 43 was observed as he sat on his bed. The resident indicated the food the facility provided was terrible. He indicated sometimes he could send the food back and they gave him something else but a lot of times there wasn't anything for them to give him because he was vegetarian. He indicated most days he got either grilled cheese or a peanut butter and jelly sandwich for his entree.On 8/7/25 at 12:17 p.m. lunch trays were observed being passed to residents in the memory care dining room. Resident 43 received two grilled cheese sandwiches and two sides.On 8/12/25 at 9:40 a.m. Resident 43's medical record was reviewed. He was a long-term care resident residing on the memory care unit whose diagnoses included but were not limited to traumatic brain injury (TBI) and depression. His diet order indicated he was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-12 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record reviews and interviews, the facility failed to offer the influenza (flu) vaccination to 2 of 5 residents reviewed for the influenza vaccination (Resident 11 and 18). Findings include:1. On 8/11/25 at 1:39 p.m., a record review was completed for Resident 11. She had the following diagnoses which included, but were not limited to, Schizophrenia, asthma, and sleep apnea. Her record lacked a consent to receive the influenza vaccination, and she did not receive the vaccination. 2. On 8/11/25 at 1:44 p.m., a record review was completed for Resident 18. He had the following diagnoses which included, but were not limited to, dementia, type 2 diabetes mellitus, chronic kidney disease, and anxiety. His record lacked a consent to receive the influenza vaccination, and he did not receive the vaccination. On 8/11/25 at 2:00 p.m., during an interview with the Regional Clinical Specialist (RCS), she indicated she could not find the consents or where the residents were administered the vaccinations. A policy titled, Influenza (Flu) Vaccination (Resident) was provided by the RCS on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-12 · tag F0887 — isolatedEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to offer a resident the COVID-19 vaccination for 1 of 5 residents reviewed (Resident 15). Findings include:On 8/11/25 at 1:32 p.m., a record review was completed for Resident 15. She had the following diagnoses which included but were not limited to Alzheimer's disease, hypertension, major depression, and anxiety. Her record lacked a consent to administer the COVID-19 vaccinations, and lacked documentation the COVID-19 vaccination was administered.On 8/11/25 at 2:00 p.m., during an interview with the Regional Clinical Specialist (RCS), she indicated she could not find the consent or where the resident was administered the COVID-19 vaccination.A policy titled, Resident COVID-19 Vaccination was provided by the RCS on 8/12/25 at 10:55 a.m. It indicated, .On admission resident(s) will be offered the COVID-19 vaccinations based on their COVID-19 vaccination history.
- Potential for harm · Dcited before2025-05-27 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to complete a physician's order to change a peripherally inserted central catheter (PICC) line for 1 of 3 residents reviewed for neglect. (Resident D) Findings include: The clinical record for Resident D was reviewed on 5/23/25 at 11:25 a.m. Diagnoses included colostomy infection, osteomyelitis, diabetes mellitus type II, and necrotizing fascititis. The resident admitted to the facility from an acute care hospital on 3/20/25. An admission Minimum Data Set (MDS) assessment, dated 3/27/25, indicated the resident had moderate cognitive impairment, had no behaviors or rejection of care, had an indwelling catheter and an ostomy, had an unstageable pressure ulcer, and received intravenous medications. A physician's order, received 3/20/25, indicated to change the peripherally inserted central catheter (PICC) dressing every seven days with a transparent dressing. The nurse needed to measure (in centimeters) the PICC catheter length (from insertion site to catheter hub) AND the nurse needed to measure upper arm circumference (10 cm…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-07-11 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure Resident Council Grievance concerns related to call light wait and response times were addressed in a timely and effective manner to prevent ongoing concerns. This deficient practice had the potential to affect 10 of 53 residents who attended the Resident Council Meeting and complained on behalf of all 53 residents who resided in the facility. Findings include: On 7/9/24 at 9:36 a.m., the call light for room [ROOM NUMBER] was observed. It was illuminated, flashed and alarmed at the nurse's station. Several staff members passed the light. On 7/10/24 at 11:00 a.m., Resident 35 was heard as she yelled out, Nurse! over and over. After five minutes, Resident 35 yelled again, with a louder voice and frustrated tone. This visitor knocked and entered her room to ask what the resident needed assistance with. Resident 35 indicated she wanted to get out of bed, but no one would listen to her. Within seconds of the visitor's entrance into…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-11 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to ensure a resident (Resident B) was treated with respect and dignity during a care plan meeting when she attempted to express her concerns for 1 of 3 residents reviewed for dignity. Findings include: On 7/8/24 at 10:16 a.m., Resident B was observed as she reclined in her bed and played a game on her smartphone. During a general and initial interview, Resident B indicated the Executive Director (ED) had hurt her feelings and made her angry. Resident B indicated she did not feel comfortable talking about the ED and was afraid she would get in trouble if she continued to complain about the way she felt she had been treated. Resident B indicated, she had been in a care plan meeting with the Social Service Director, the Minimum Data Set Coordinator (MDSC) and her best friend who helped her coordinate her care was on speakerphone. During the meeting, the ED had been asked to come to the room since Resident B and her friends had several…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-11 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
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 observations, interview, and record review, the facility failed to ensure a resident, (Resident 3) was included and engaged in a meaningful activity program according to her routine and preferences to maintain and/or enhance her quality of life as a totally dependent resident for 1 of 3 residents reviewed for Activity Programming. Findings include: On 7/8/24 at 10:43 a.m., Resident 3 was initially observed in bed in her room. She wore a hospital gown, her hair was flattened on one side, and her lips and gums were observed to have a buildup of unidentified goopy debris. Her side of the room was darkened as the privacy curtain between her, and her roommate's side had been pulled so that the natural light from her roommate's window could not be viewed. The ceiling lights were off. Resident 3's TV was off, and there was no music. She was positioned in bed with the head of her bed (HOB) elevated as her tube feeding pump was hooked up and running. Resident 3 leaned on her left side, and her eyes were open,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 14 citations
- Potential for harm · Dcited before2024-07-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents environment remained free of accident hazards when medications were not secured for 2 of 8 residents reviewed for secured medication (Resident E and 12). Findings include: 1. On 7/8/24 at 12:20 p.m., Resident E was observed to have her albuterol rescue inhaler in the dining room. The MCSS (Memory Care Support Specialist) indicated to the resident she needed the resident to give her the albuterol inhaler. The resident indicated she could not have it. The MCSS did not get the albuterol inhaler before Resident E went to her room. During a conversation, in her memory care (MC) room, on 7/8/24 at 12:28 p.m., Resident E indicated she still had her albuterol inhaler in her room. She showed the inhaler in her pocket. During an interview, on 7/8/24 at 12:32 p.m., Regional Support Services indicated she was getting agitated in the dining room, so they would re-approach her later. During an interview, in her MC room, on 7/10/24 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.
- Potential for harm · Dcited before2024-07-11 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and record review, the facility failed to ensure appropriate mediation storage was implemented when single-dose vials were labeled and dated, stored external medications from internal medications and dated inhalers once opened for 2 of 4 medications carts observed (Carts 100 hall and 300 hall). Findings include: 1. On 7/8/24 at 9:45 a.m., the 300-hall medication cart was observed. The following was observed inside the cart: a. Hydrophilic wound care dressing (a topical ointment) was observed in a drawer with oral inhalers. b. Lidocaine injectable solution was in the cart and did not have a label or date on the vial. c. Resident 208 had an albuterol HFA 90mcg (microgram) inhaler. It lacked a date to indicate when it was opened. She also had an incruse ellipta 62.5 inhaler. It lacked a date to indicate when it was opened. d. Resident 21 had a breziri aerosol inhaler. It lacked a date to indicate when it was opened. e. Resident 46 had an albuterol sul inhaler 90mcg. It lacked a date to indicate when it was opened. 2. On 7/8/24 at 10:10 a.m., the 100-hall…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-11 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to administer a pneumococcal vaccination to a resident who gave consent to receive the vaccination for 1 of 4 residents reviewed for vaccinations (Resident 35). Findings include: On 7/11/24 at 10:25 a.m., a record review was completed for Resident 35. She had the following diagnoses which included but were not limited to unspecified dementia, unspecified protein-calorie malnutrition, type 2 diabetes, and asthma. On 3/26/24, the resident's responsible party signed a consent for Resident 35 to receive a pneumococcal vaccination. It was not administered. On 7/11/24 at 11:25 a.m., the Regional Director of Clinical Services (RDCO) indicated the vaccination was not administered and she would get it scheduled today. A policy was provided by the RDCO on 7/10/24 at 2:02 p.m. It indicated, .On admission resident(s) will be screened for pneumococcal vaccination. If a resident meets criteria .will be offered the vaccination . 3.1-18(b)(5)
- Potential for harm · Fcited before2023-05-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — widespreadEnsure 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 hot water temperatures were safe for 4 of 7 resident rooms reviewed for excessive hot water temperatures, and failed to ensure a resident who was at risk for falls with a history of repeated falls had appropriate fall interventions in place to prevent the potential for additional falls (Resident 2). Findings include: 1. During a tour with the Maintenance Supervisor, on 5/21/23 at 2:14 p.m., several resident rooms were checked for excessive hot water temperatures in resident bathrooms. a. room [ROOM NUMBER] water temperature was 125.3 degrees Fahrenheit (F). b. room [ROOM NUMBER] water temperature was 133.1 degrees F. c. room [ROOM NUMBER] water temperature was 128.4 degrees F. d. room [ROOM NUMBER] water temperature was 131 degrees F. On 5/21/23 at 2:28 p.m., the Maintenance Supervisor indicated he knew the facility needed the mixing valves rebuilt. At least he was hoping to get the mixing valves rebuilt. They have been acting up…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-05-26 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a medication cart remained locked while unauthorized residents and visitors passed it for 1 of 1 random observation, and further failed to ensure a resident did not have medications in his room without a self-administration assessment for 1 of 1 resident reviewed for self-administration assessments (Resident 17). Findings include: 1. On 5/24/23 at 9:42 a.m., Licensed Practical Nurse (LPN) 52 was observed removing a 3 milliliter (mL) albuterol nebulizer treatment medication for Resident 17. She did not lock the medication cart when she walked away and off the unit. There was no nurse in line of sight of the cart, the nurse's station was empty. On 5/24/23 at 9:42 a.m., Mattress Company Employee 71 was at the facility to change out several mattresses. He was observed standing near the unlocked and unattended medication cart. On 5/24/23 at 9:44 a.m., Resident 17 was observed outside his room in a wheelchair, waiting for his nebulizer treatment and new mattress. On 5/24/23 at 9:45 a.m., the DON acquired…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-05-26 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure supplies and foods were stored appropriately, food was dated and labeled, the kitchen was sufficiently cleaned, sinks were not leaking in kitchen area, and the dumpster lids were closed for 1 of 1 days of kitchen observation. Findings include: On 5/21/23 at 10:14 a.m., [NAME] 12 provided a tour of the kitchen. In the dry storage area: a. Two boxes of plastic utensils were open to the air with the inner plastic bag around the outside of the boxes. b. A bag of pork flavored gravy mix was open to the air. c. A bag of Quaker grits, with no open date, was rolled down and not sealed. The reach-in refrigerator: a. A large plastic container of gravy had no label or date. b. A large container of American cheese was not dated. c. Five single serving containers of pureed bread were not dated. [NAME] 12 indicated he did not know when they were prepared. d. A container of ham salad was dated to expire on 4/28/23. e. A container of romaine lettuce was open to the air. f. A foil wrapped cheddar cheese was opened, the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-05-26 · tag F0882 — patternDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to designate a qualified person to fulfill the role of the Infection Preventionist (IP) at least part-time. This deficient practice had the potential to effect 54 of 54 residents who resided at the facility. Findings include: During an interview with the and DNS on 5/26/23 at 11:46 a.m., she indicated she had earned a certificate for IP in July of 2019. She indicated she was performing the role of the IP nurse for the facility. The facility assessment was reviewed on 5/26/23 at 12:00 p.m. It indicated there was a position of an IP nurse and next to the position it indicated, Based on characteristics of facility, does this role need to be dedicated solely to the IPCP (Infection Prevention Control Program)? A policy titled COVID-19 Policy, dated 9/27/22, was provided by the ED on 5/22/23 at 11:06 a.m., indicated, .The facility will follow CMS and IDOH guidelines.
- Potential for harm · D2023-05-26 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 observation, interview and record review, the facility failed to ensure person-centered comprehensive care plans were reviewed and revised in a timely manner to accurately reflect the resident's conditions for 3 of 5 residents reviewed for care plans (Resident 18, 21, and 52). Findings include: 1. On 5/22/23 at 10:50 a.m., Resident 52 was observed lying in bed with the sheet off of his lower legs. Resident 52 did not have any wound dressings on his feet. Resident 52 indicated he did not have any wounds on his feet. A comprehensive record review was completed on 5/24/23 at 12:30 p.m. He had the following diagnoses, but not limited to acute infarction of the spinal cord, muscle weakness, anxiety, orthostatic hypotension, neurogenic bowel, neuropathic bladder, and paraplegia. The record lacked documentation of any physician's orders for treatments and current wound measurements to Resident 52's feet. Resident 52 had a care plan dated 3/13/23 that indicated he admitted to the facility with a pressure injury to his left heel. He was at risk for impaired healing due to paraplegia…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-05-26 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure residents received appropriate nail care for 3 of 3 residents reviewed for nail care (Residents 20, 211, and 212). Findings include: 1. On 5/21/23 at 11:30 a.m., 5/22/23 at 9:40 a.m., and 5/23/23 at 11:20 a.m., Resident 211 was observed lying in bed. His fingernails were long with a dark brown substance under his nails. During an observation on 5/24/23 at 10:59 a.m., Resident 211 was sitting up in the dining room with a hospital gown on. He indicated he wanted to keep his facial hair and wound like a haircut. His nails were trimmed and clean. A record review was completed on 5/25/23 at 11:09 a.m. Resident 211 had the following diagnoses, but not limited to sepsis, protein-calorie malnutrition, benign prostatic hypertrophy, obstructive uropathy, weakness, cognitive communication deficit, malignant neoplasm of the bronchus of the lung, malignant neoplasm of the brain, and pulmonary embolism. His care plan, dated 5/15/23, indicated he was a new admission to the facility, and he required implementation of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-26 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide 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 assess a resident who had limitations in his right shoulder related to a history of falling on his shoulder with surgery and provide necessary treatment and services to prevent potential worsening of the limitation and injury of his right shoulder for 1 of 1 resident reviewed for physical limitations (Resident 9). Findings include: During an interview with Resident 9 on 5/22/23 at 11:08 a.m., he indicated he had a fall prior to admitting to the facility and fractured his right arm and tore his rotator cuff. Resident 9 demonstrated his limitations to the right arm by attempting to raise his arm above his head and he could not raise his arm completely. Resident 9 indicated he was right-handed. During an interview with Resident 9 on 5/23/23 at 2:13 p.m., he indicated he had a shower the evening prior. The unidentified aide caring for him sat in the shower room and did not assist him with his shower. He indicated he needed help due to the limitation and pain of his right shoulder. On 5/23/23 at 2:30 p.m., a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
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' respiratory tubing and equipment was functional, dated, and stored properly for 2 of 2 residents reviewed for respiratory care (Residents 17 and 40), and the facility failed to ensure a resident's oxygen was administered at the proper liters per minute for 1 of 2 residents reviewed for respiratory care (Resident 40). Findings include: 1. On 5/21/23 at 11:32 a.m., Resident 17 was observed receiving oxygen at 4 liters per minute (lpm) via nasal cannula (NC). The humidity bottle on the oxygen concentrator was undated and the tubing was twisted and kinked closed. His nebulizer mouthpiece was uncovered. On 5/22/23 at 10:37 a.m., Resident 17 was observed receiving oxygen at 4 lpm via nasal cannula. The humidity bottle on the oxygen concentrator was undated and the tubing was twisted and kinked closed. On 5/23/23 at 10:01 a.m., Resident 17 was observed receiving oxygen at 4 lpm via nasal cannula. His nebulizer mask was uncovered. On 5/23/23 at 10:58 a.m., Resident 17's record was reviewed. His diagnoses…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-26 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to complete a pre and post dialysis observation and ordered weight monitoring for 1 of 1 resident reviewed for dialysis (Resident 18). Findings include: A record review was completed on 5/25/23 at 2:30 p.m. Resident 18 had the following diagnoses, which included, but were not limited to type 2 diabetes mellitus, end stage renal disease, anemia, essential hypertension, chronic obstructive pulmonary disease, and myocardial infarction. Resident 18 had current orders to receive hemodialysis every Monday, Wednesday, and Friday. Resident 18's dialysis events were reviewed from March 1, 2023, thru May 25, 2023. The majority of pre and post Dialysis assessments had not been completed. The record lacked documentation of additional pre and/or post dialysis assessments. Resident 18 had previous physician's orders to be weighed daily revised on 5/22/23 This order was changed on 5/22/23 to weigh every Monday, Wednesday, and Friday. Resident 18's weights were reviewed from March 1, 2023, thru May 25, 2023. Multiple weights were missing.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-26 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the nursing staff failed to follow-up with a resident who was short of breath, allowing his oxygen saturation to get to 76% for 1 of 1 random observation of a resident short of breath (Resident 17), and failed to ensure the medication cart was locked and supervised while residents, visitors and staff walked by for 1 of 1 random observation of nursing staff. Finding include: On 5/24/23 at 9:28 a.m., Resident 17 was observed in the common area lounge with his catheter tubing on the floor. The resident indicated he was out here because they were changing out his mattress. He indicated he was out of breath. He indicated he had to lay still in bed, so he was not out of breath. He was dressed in a gown tied closed in the back. On 5/24/23 at 9:37 a.m., Licensed Practical Nurse (LPN) 51 checked on Resident 17 after someone else noted he was short of breath. His oxygen (O2) saturation was 90. Resident 17 indicated it usually ran at 92. His O2 was on at 4 lpm. On 5/24/23 at 9:41 a. m., LPN 52 turned the resident and moved him about 6 feet…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-26 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to administer a medication for high blood pressure as needed when a resident's blood pressure was elevated for 1 of 5 residents reviewed for medications (Resident 18). Findings include: A record review was completed on 5/25/23 at 2:30 p.m. Resident 18 had the following diagnoses but not limited to type 2 diabetes mellitus, end stage renal disease, weakness, seizures, neuropathy, absence of left leg below knee, benign prostatic hypertrophy, anemia, essential hypertension, chronic obstructive pulmonary disease, depression, and myocardial infarction. As of the review date of 5/25/23, Resident 18 had a current order to administer hydralazine 10 milligrams (mg) daily as needed for a systolic blood pressure greater than 150 and a diastolic blood pressure (BP) greater than 90. Review of the April 2023 and May 2023 Medication Administration Records indicated Resident 18 did not receive the medication when his blood pressure (BP) was documented as elevated on the following days: 5/25/23 with a BP of 164/94 5/22/23 with a BP of 158/90…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.9 | +0.1 vs chain |
| Health inspection | 3 of 5 | 3.4 | -0.4 vs chain |
| Staffing | 2 of 5 | 2.3 | -0.3 vs chain |
| Quality measures | 5 of 5 | 4.7 | +0.3 vs chain |
The other 89 homes this chain runs (chain average 3.9★, per CMS)
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 / manager | Type | Role | Since |
|---|---|---|---|
| KELSEY, DONNA | Individual | CONTRACTED MANAGING EMPLOYEE | since 06/01/2016 |
| STORDY, DAVID | Individual | CONTRACTED MANAGING EMPLOYEE | since 09/15/2016 |
| VAN CAMP, STEVEN | Individual | CONTRACTED MANAGING EMPLOYEE | since 09/06/2019 |
| BABCOCK, PAUL | Individual | CORPORATE OFFICER | since 09/30/2020 |
| AMERICAN SENIOR COMMUNITIES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2009 |
| HEATH, GENEVA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 02/11/2019 |
| WILSON, KEITH | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 08/14/2020 |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
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.
This home reported $654K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Indiana Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 155383. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-12, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
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.