Waters Of Indianapolis, The
3895 S Keystone Ave, Indianapolis, IN 46227 · For profit - Limited Liability company · 81 certified beds · (317) 787-5364 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- CMS has flagged it for abuse
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Dec 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- 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 independent health-inspection rating is low (2/5)
- 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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 3 of 5 |
| Long-stay residentspeople who live here | 3 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 fell from 3 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 2.8% | 11.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.5% | 5.5% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 1.7% | 0.4% | 0.9% | worse 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 | 96.8% | 25.2% | 6.5% | worse 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 | 6.5% | 3.9% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 7.0% | 11.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 32.9% | 23.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 90.4% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.2% | 3.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 26.5% | 23.3% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 18.2% | 13.6% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 18.5% | 79.0% | 79.4% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.65 | 1.61 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.94 | 1.44 | 1.80 | typical |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.21 therapist hours per resident per day in 2026Q1 — more than 24% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 5% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.9%CMS range 7.2–17.1 | 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 | 1.48 | 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 81 beds and averages 64.4 residents a day — about 80% occupied, or roughly 17 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.29 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.552 is at or above 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 3.00 hrs/resident/day on weekends vs 3.41 on weekdays — 12% thinner on weekends. RN hours go from 0.64 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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 10 most serious are shown; the remaining 15 are one tap away and print in full.
- Potential for harm · Dcited before2025-12-31 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to protect a resident's right to be free from sexual abuse for 1 of 3 residents reviewed for abuse. A male resident was observed leaving a female resident's room. The female resident indicated the male resident touched her breast. (Resident B, Resident C) Findings include:On 12/30/25 at 9:09 a.m., the Director of Nursing (DON) provided a copy of a facility reportable incident, dated 12/5/25 at 12:30 p.m. A review of the reportable incident brief description indicated Resident C made an allegation that Resident B touched her breast.During an interview on 12/31/25 at 8:15 a.m., Resident C was unable to describe the details of a sexual abuse allegation that she made against Resident B. Resident C repeated the word fine after each question of the interview. The clinical record for Resident B was reviewed on 12/31/25 at 9:02 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, hemiplegia that affected his right side, and diabetes.An annual Minimum Data Set (MDS) assessment, dated 9/27/25, indicated Resident B…
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 before2025-12-31 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a full description of an allegation of sexual abuse was reported to the state health department for 1 of 3 residents reviewed for abuse. A male resident was observed leaving a female resident's room. The female resident was found lying in her bed with the sheet pulled down, her brief unlatched on one side and bent down in the front, and her gown pulled up. (Resident B, Resident C) Findings include:On 12/30/25 at 9:09 a.m., the Director of Nursing (DON) provided a copy of a facility reportable incident, dated 12/5/25 at 12:30 p.m. A review of the reportable incident brief description indicated Resident C made an allegation that Resident B touched her breast.During an interview on 12/31/25 at 8:15 a.m., Resident C was unable to describe the details of a sexual abuse allegation that had been made against Resident B. Resident C repeated the word fine after each question of the interview. On 12/31/25 at 8:30 a.m., the DON provided a copy of a written statement from CNA 1, dated 12/5/25 at 11:50 a.m. (approximately 1 hour…
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 · D2025-07-21 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake 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 provide a safe and comfortable environment when the bathroom wall heater covers were removed leaving the metal heating elements exposed for 3 of 3 random observations; and failed to ensure the bathroom door frames were free from rust and decay for 2 of 3 random observations. Findings include:1. During a random observation of the secured memory care unit, on 7/21/25 from 8:25 a.m. until 9:05 a.m., observed the bathroom wall heaters in rooms H-8, H-10, and H-11. Each of the bathroom wall heaters were approximately six inches from the floor. The front cover of the heaters had been removed, which left approximately 40 small silver metal discs lined in a row across the inside of the heater exposed. During an interview, on 7/21/25 at 12:00 p.m., the Maintenance Supervisor indicated the heaters were still in working order and the heating elements should not have been left exposed to the residents. 2. During a random observation of the secured memory care unit, on 7/21/25 from 8:25 a.m. until 9:05 a.m., observed the bathroom door…
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 · Fcited before2025-06-26 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 dietary staff's facial hair was covered to prevent exposure to food and drinks while in the kitchen for 1 of 2 observations. This had the potential to affect 63 of 63 residents residing in the facility who received food from the kitchen. (Dietary Aide 2) Finding includes: During a kitchen observation on 6/22/25 from 11:40 a.m. to 12:45 p.m., the following was observed: - Dietary Aide 2 was observed in the kitchen near the prepared foods that were uncovered on the steam table. Dietary Aide 2 was observed to have facial hair on his chin approximately one fourth inch in length and was observed scooping ice from the ice machine into glasses, pouring drinks from a pitcher to be served to the residents. Dietary Aide 2 was not observed to be wearing beard net. During an interview on 6/22/25 at 12:45 p.m., the Dietary Manager indicated that staff's hair should be covered when in kitchen. During an interview on 6/22/25 at 1:04 p.m., the Assistant Director of Nursing indicated that hair nets should be worn when…
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 · E2025-06-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the facility was free from accident hazards for 1 of 1 observation, potentially affecting 13 of 19 self-mobile cognitively impaired residents residing in the Memory Care Unit. An electrical cord was observed on the floor in the middle of a walkway area that was used by the residents. (Resident 29) Finding includes: During an observation of the Memory Care Unit on 6/23/25 from 9:00 a.m. to 9:10 a.m., the following was observed: - The Floor Technician was using an electric buffer/scrubber (buffer) machine on the floor space between rooms [ROOM NUMBERS]. The machine's yellow colored electric cord was approximately one inch in circumference and was approximately 20 feet in length. The cord was observed to be plugged into the hallway outlet located near room [ROOM NUMBER]. As the Floor Technician used the buffer machine, he was observed moving from one side of the hallway to the other side of the hallway as he made his way from room…
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 · D2025-06-26 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the person-centered comprehensive care plan was developed for 1 of 21 residents reviewed for care plans. The care plan was not developed for a resident who was at risk for falls and whose preference was to keep the bed in the high position. (Resident 42) Finding includes: On 6/22/25 at 10:22 a.m., Resident 42 was observed resting in bed. The bed was located next to the wall with the resident's right side near the wall. Resident 42's bed was observed to be in the highest position and was approximately 40 inches above the floor. The handheld bed control device was observed on the bed and within reach of the resident. No staff were visible in the area during that time. During an interview at that time, Resident 42 indicated she was able to adjust the height of the bed and she liked it in the highest position. On 6/22/25 at 12:33 p.m., Resident 42 was observed resting in bed while eating her noon meal. The bed was located next to the wall with the resident's right side near the wall. Resident 42's bed 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 · D2025-06-26 · tag F0659 — isolatedProvide care by qualified persons according to each resident's written plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a medication was administered by qualified personnel for 1 of 19 residents reviewed for medication administration. (Resident B) Finding includes: On 6/24/25 at 1:00 p.m., the Director of Nursing (DON) provided a copy of a facility reportable incident, dated 5/26/25. The incident indicated on 5/26/25, Resident B reported to the facility that on 5/25/25, CNA 8 administered medication that Resident B believed was Tylenol. On 6/24/25 at 1:22 p.m., the Director of Nursing provided a copy of the facility investigation. The investigation included, but was not limited to: The Administrator's written statement, dated 5/26/25, indicated the Administrator had interviewed CNA 8. CNA 8 admitted giving Resident B pills. CNA 8 obtained the tylenol from behind the nurses station and gave them to the Resident B because he did not want the resident to have to wait for the nurse. An email from RN 10, dated 5/26/25, indicated RN 10 had worked on the night of the incident. Resident B was under her care that night. RN 10 was not aware…
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 before2025-06-26 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure a treatment cart was securely locked for 1 of 1 random observations. (Faith Hall Treatment Cart) Finding includes: On 6/22/25 from 8:15 a.m. to 8:30 a.m., observed a treatment cart on the Faith Hall to be unlocked and easily opened. No staff were observed in the area. Several residents were sitting in the hall in wheelchairs approximately 4 feet from the cart. The contents of the treatment cart, included but was not limited to: - multiple 0.5 oz tubes of Antifungal cream 2% (used to treat a skin fungus). The label indicated Keep out of reach - multiple 60 gram tubes of Fludocinonide cream 0.05% (used to treat inflammation of the skin). The label indicated Keep out of reach - multiple 1 ounce tubes of gentamicin cream 1%, (used to treat skin infections). The label indicated Keep out of reach. During an interview on 6/22/25 at 8:30 a.m., LPN 3 indicated the cart should have been locked. On 6/23/25 at 2:08 p.m., the Administrator provided a policy titled Medication Storage In The Facility, dated July 2024, and indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-26 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to implement infection control practices for 2 of 5 residents reviewed for immunizations. The two-step tuberculosis skin test series was not completed. (Resident 15, Resident 58) Findings include: 1. On 6/22/25 at 10:10 a.m., Resident 15's clinical record was reviewed. Resident 15's diagnoses included, but were not limited to, paraplegia (paralysis of the legs or lower body), bipolar disorder (a mental illness characterized by extreme shifts in mood, energy, and activity levels), and chronic osteomyelitis (an infection of the bone). Resident 15 had an admission date of 1/16/25. Resident 15's TB (tuberculosis) test administration history indicated that the resident had an order for a first step TB skin test to be administered 1/17/25 which had been coded on the EMAR (electronic medication administration record) as a 2, which indicated the resident refused the administration. The second step TB skin test ordered for 1/31/25 indicated other/see nurse note. Neither the first step or the second step TB skin test were documented as…
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 · D2025-03-21 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to protect the residents' rights to be free from misappropriation of property for 1 of 3 residents reviewed for misappropriation of medications. (Resident C) Finding includes: On 3/21/25 at 9:50 a.m., the clinical record for Resident C was reviewed. The diagnoses included, but were not limited to, Type 2 diabetes mellitus (a chronic condition affecting blood sugar levels). An admission MDS (Minimum Data Set) assessment, dated 2/7/25, indicated Resident C was cognitively intact. A physician's order, initiated 2/8/25 and discontinued on 3/1/25, indicated Resident C had tirzepatide (an antidiabetic medication used to treat type 2 diabetes and for weight loss) 15 mg (milligrams)/0.5 mL (milliliters) ordered to be given by subcutaneous (under the skin) injection once weekly on Saturdays. A physician's order, initiated on 3/7/25 and with no end date, indicated Resident C had tirzepatide, 15 mg/0.5 mL ordered to be given by subcutaneous injection once weekly on Fridays. During an interview on 3/21/25 at 10:30 a.m., the Administrator…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 15 citations
- Potential for harm · Dcited before2025-02-07 · 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
Based on interview and record review, the facility failed to ensure resident rights were maintained when a cognitively intact resident was not allowed to sign out for a leave of absence for 1 of 3 residents reviewed for resident's rights. (Resident C) Findings include: During an interview on 2/6/25 at 9:42 a.m., Resident C indicated the staff had told her that she cannot sign out and leave the facility for a leave of absence and they had not let her leave. During an interview on 2/6/25 at 1:09 p.m., the Director of Nursing (DON) indicated Resident C was allowed to sign out and leave the facility with family or friends, but not with her boyfriend. Resident C was not allowed to sign out on her own even though she was cognitively intact. The DON did not think Resident C's rights were violated. The clinical record was reviewed on 2/7/25 at 12:13 p.m. The diagnoses included, but were not limited to, alcohol abuse, psychoactive substance abuse, and bipolar disorder. An admission Minimum Data Set (MDS) assessment, dated 12/25/24, indicated Resident C was cognitively intact. A current…
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 before2025-02-07 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to report an allegation of abuse for 1 of 3 residents reviewed for abuse. Staff did not immediately report to the administrator when staff overheard a female resident tell a male staff member she would report him for hitting her and did not accurately report all known information regarding the allegation of abuse at the time the allegation was reported to the state survey agency. (Resident B, CNA 1, CNA 2, DON, Floor Tech) Findings include: During an interview on 2/6/25 at 10:02 a.m., Resident B indicated a couple of weeks ago, in the morning, she was wheeling down the hall and attempted to pass the Floor Technician (Floor Tech), from behind, as he was buffing the floor. The machine was plugged in and the cord was across the floor, and Resident B was on his left. The Floor Tech stuck out his left arm and hit her right shoulder. Resident B said I'm telling that you hit me. Resident B didn't think the Floor Tech. intended to hit her. Resident B couldn't remember the date this happened, but thought it happened between 1/20/25…
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 · D2025-02-07 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to follow the abuse policy and ensure an alleged perpetrator of abuse was immediately removed from the facility for 1 of 3 residents reviewed for abuse. (Resident B, Floor Tech, CNA 1, CNA 2) Findings include: During an interview on 2/6/25 at 10:02 a.m., Resident B indicated a couple of weeks ago, in the morning, she was wheeling down the hall and attempted to pass the Floor Technician (Floor Tech), from behind, as he was buffing the floor. The machine was plugged in, the cord was across the floor, and Resident B was on his left. The Floor Tech stuck out his left arm and hit her right shoulder. Resident B said I'm telling that you hit me. Resident B didn't think the Floor Tech intended to hit her. Resident B couldn't remember the date this happened, but thought it happened between 1/20/25 and 1/22/25. During an interview on 2/6/25 at 10:16 a.m., the Floor Tech indicated, on the morning of 1/22/25, he was buffing the floor when Resident B wheeled the front wheels of her wheelchair over the power cord to the buffer. He told…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-07 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure medications were stored in accordance with accepted professional principles for 2 of 3 residents observed for medication administration. An unlabeled medication was not removed from the medication cart and eye drops were not dated when opened. (Resident D, QMA 1, LPN 1) 1. During a medication pass observation on 2/6/25 at 8:09 a.m., Qualified Medication Aide (QMA) 1 pulled a pill packet out of the medication cart. The packet had the label torn off so there was no resident name, no medication name or strength, and no instructions. Two white round pills with 54/24 on one side of each pill were observed. At that time, QMA 1 indicated the medication packet with the label removed should not have been left in the medication cart because she didn't know who the medication was for, what the medication was, nor the directions. During an interview on 2/6/25 at 10:32 a.m., the Director of Nursing (DON) indicated the medication packet with the label removed should have been removed from the medication cart. 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 · Dcited before2025-02-07 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 during the administration of eye drops for 1 of 3 residents reviewed for medication administration. (Resident D, LPN 1) Findings include: During a medication pass observation on 2/6/25 at 8:46 a.m., Licensed Practical Nurse (LPN) 1 carried a bottle of Zaditor 0.035% eye drops (antihistamine eye drop used to treat itchy eyes) into Resident D's room. LPN 1 was not observed to be wearing gloves. LPN 1 explained what she was going to administer and took a pair of clean gloves out of a box and donned the gloves while holding the eye drops. LPN 1 was not observed to perform hand hygiene before donning the gloves. LPN 1 ensured Resident D was sitting up in his chair and leaned his head back, gently pulled down the lower right eye lid, and administered one drop into the outer edge of the right eye and applied pressure for three seconds. Then LPN 1 pulled the left lower eye lid down, administered one drop into the outer left eye and applied pressure for three seconds. LPN 1…
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 before2024-11-14 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by a CNA for 1 of 5 resident reviewed for abuse. (CNA 3, Resident B) Finding includes: On 11/14/24 at 9:25 a.m., the clinical record of Resident B was reviewed. The diagnoses included, but were not limited to, cerebral infarction (a reduction of blood flow to the brain), encephalopathy (a brain disorder), and cognitive communication deficit. On 11/14/24 at 9:35 a.m., the Administrator provided a facility reportable incident, dated 10/18/24. The incident indicated that on the previous evening shift, on 10/17/24, CNA 3 spoke to Resident B in an upsetting tone. CNA 3 was suspended pending investigation of the allegations and was terminated the same day after obtaining interviews from Resident B and other witnesses present. During an interview on 11/14/24 at 10:20 a.m., a witness to the 10/17/24 smoking break incident said that CNA 3 was upset about taking the residents out for their evening smoke break because it wasn't CNA 3's assignment. CNA 3 was observed by 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 · D2024-06-03 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 self-medication administration assessment was completed for residents with medications left at bedside for 1 of 1 random observations. (Resident 125) Finding includes: During a tour on 5/28/24 at 8:59 a.m., observed Resident 125's room, no staff were observed to be in the room or in hallway. Resident 125 was up in a wheelchair and on top of the bedside table one clear plastic cup filled with six tablets, one capsule, and one gelcap was observed. On 5/29/24 9:30 a.m., Resident 125's clinical record was reviewed. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, alcohol dependence, and anxiety. Resident 125's clinical record lacked a Self-Medication Administration Assessment. During an interview on 5/29/24 at 9:05 a.m., RN 2 indicated medication should not be left unattended in resident rooms. During an interview on 5/31/24 at 8:37 a.m., the Director of Nursing indicated that no medications are to be left in a resident's room. On 5/29/24 at 12:58 p.m., the 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.
- Potential for harm · D2024-06-03 · tag F0926 — failed to keep the home smoke-free / fire-safe — isolatedHave policies on smoking.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to perform safe smoking assessments per facility policy for 1 of 5 residents reviewed for safe smoking. (Resident 1) Findings include: On 5/28/24 at 1:15 p.m., Resident 1's clinical record was reviewed. The diagnoses included, but were not limited to, multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves causing muscle weakness and problems with coordination), muscle wasting and atrophy, flaccid hemiplegia (paralysis on one side of the body) affecting right dominant side, and unsteadiness on feet. A Quarterly MDS (Minimum Data Set) assessment, dated 3/21/24, indicated Resident 1 had moderate cognitive impairment. The Care Plan included, but was not limited to: Resident 1 is a supervised smoker as evidenced by current smoking assessment and must be supervised during smoking activity, initiated on 8/7/18. The most recent Smoking Risk Assessment in Resident 1's clinical record had an effective date of 9/19/22 and indicated the following for Resident 1: - required the use of 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 · Ecited before2023-11-09 · 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 pans and cooking utensils were cleaned in a sanitary manner for 2 of 2 kitchen observations. Finding includes: On 11/8/23 at 12:06 p.m., an open meal tray cart was observed. All the meals and drinks were observed to be served in styrofoam boxes and styrofoam cups with plasticware. During an interview on 11/8/23 at 12:09 p.m., RN 1 (Registered Nurse) indicated the facility had been serving meals on styrofoam for a while now. During an interview on 11/8/23 at 12:59 p.m., Dietary Aide 1 indicated the dishwasher had been broken. He indicated if the dietary staff took the time to clean all the silverware, pots and pans, and dishes they wouldn't have the time to make food. At that time, the dishwashing area was observed. Across from the dishwasher, was a 3 compartment sink. Above the sink, was a sign, taped to the wall, that indicated the instructions for using the 3 compartment sink, a detergent dispenser, and a sanitizer dispenser each with a hose that reached down to the sinks. The instructions indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-09 · 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
Based on observation, interview, and record review the facility failed to protect the resident's right to be treated with dignity for 2 of 3 residents reviewed. Meals were served on styrofoam and residents were wearing two incontinence briefs. (Resident B, Resident C) Finding includes: 1. During an interview on 11/8/23 at 8:24 a.m., Resident B indicated he never requested styrofoam cups. Resident B used the styrofoam cups because that is what the staff gave him. He thought the staff gave him styrofoam because it was quick and easy and it wasn't that important to make sure Resident B had a regular coffee cup with a lid. Resident B would rather have drank coffee out of a regular coffee cup and a handle and lid, but he used the styrofoam because that is what the staff gave him. Resident B was observed to be wearing two incontinent briefs. The brief closest to his skin was soaked with urine. At that time, Resident B indicated he wasn't sure how long the brief had been wet, but thougt it was last changed, around 4:00 a.m., and Resident B believed staff put two briefs on him so they…
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 · E2023-06-16 · tag F0727 — failed to provide required RN coverage — patternHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to provide 8 continuous hours of Registered Nursing (RN) services, seven days a week, for 12 of 31 days reviewed. Findings include: On 6/15/23 at 1:00 p.m., the Director of Nursing (DON) provided copies of the Daily Staffing Sheets for 5/13/23 through 6/12/23. On 6/16/23 at 8:15 a.m., the DON provided copies of the Report of Nursing Staff Directly Responsible for Resident Care for each day in the reviewed period of 5/13/23 through 6/12/23. A review of these reports included, but was not limited to the following data for each calendar day: facility census; number of hours worked for each of the three work shifts for the day, evening, and night shifts; the number of Registered Nurses who worked that shift; and number of hours worked. A review of this period utilizing both sets of daily staffing reports indicated the following: On 5/13/23, the reports lacked documentation to indicate any RN coverage was provided. The facility census was 70. On 5/17/23, the reports lacked documentation to indicate any RN coverage was provided.…
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 before2023-06-16 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure foods were served in a sanitary and safe manner for 6 of 7 kitchen observations. Staff hair was not covered while in the kitchen food preparation area and the steam table was in disrepair. (Dietary Aide 2, Dietary Aide 3, [NAME] 4, Dietary Manager, and Maintenance Director) Findings include: 1. During the initial kitchen tour with the Dietary Manager (DM), on 6/12/23 from 7:32 a.m. to 8:10 a.m., the following was observed: a. The DM was observed walking through out the kitchen area where the breakfast meal was being served. The DM was observed to have hair braids located on the right side of the head just above the ear and a 10-inch single braid hanging in the middle of the back. The hair braids were observed to not be covered. b. Dietary Aide 2 was observed walking through out the kitchen area where the breakfast meal was being served. Dietary Aide 2 was observed to have facial hair (beard and mustache) approximately one-fourth inch in length. Dietary Aide 2's facial hair was observed to not be…
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 · D2023-06-16 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's medications were reconciled before discharge for 1 of 3 residents reviewed for discharge. (Resident 29) Finding includes: On 6/25/23 at 9:51 a.m., Resident 29's closed clinical record was reviewed. Resident 29 discharged to home on 6/6/23. A Resident Discharge summary, dated [DATE], indicated all Resident 29's medications were sent home with the resident. The discharge summary lacked the quantity of each medication, the dosage of each medication, the instructions for each medication, and staff signatures. The discharge medication included, but were not limited to: - Midodrine (a medication used to treat high blood pressure) HCL 5 mg (milligrams), no instructions for frequency. - Atorvastatin calcium (a medication used to treat high cholesterol), no dosage or instructions for frequency. - Apixaban (a blood thinner), no dosage or instructions for frequency. - Multivitamin, no dosage or instructions for frequency. - Torsemide (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 · D2023-06-16 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow vaccine administration guidelines for the pneumococcal vaccine. The pneumococcal vaccine was not given for residents who had consented to receive the vaccinations for 3 of 8 resident reviewed for vaccines. (Resident 5, Resident 26, Resident 52) Findings include: 1. On 6/14/23 at 10:40 a.m., Resident 5's clinical record was reviewed and indicated the following: Resident 5's immunization records indicated Resident 5 received a pneumococcal polysaccharide 23 (PPSV 23) vaccine on 8/3/16 and on 3/13/17 but lacked documentation of any subsequent pneumococcal conjugate (PCV 13, 15, or 20) vaccines. Resident 5's diagnoses included, but were not limited to, chronic obstructive pulmonary disorder (COPD, a group of diseases that cause airflow blockage and breathing-related issues), hypertension (high blood pressure), and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). Resident 5 had an admission date of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2023-06-16 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the dumpster container top lids and a side panel door were kept closed when not in use and failed to ensure the dumpster container area was free of debris, for 2 of 2 observations. Findings include: 1. During the initial facility tour with the Dietary Manager (DM), on 6/12/23 from 8:15 a.m. to 8:20 a.m., the dumpster container area, located across the parking area from the kitchen's back door, was observed. The dumpster container had 2 top lids. Two of two lids were observed to not be closed. The dumpster container also had two sliding side panel doors. One of two sliding side panel doors was observed to not be closed. Inside the dumpster were multiple filled trash bags and other debris. The ground surrounding the dumpster area was littered with debris (used plastic gloves, plastic eating utensils, plastic cups, paper plates and other unidentifiable items). Behind the dumpster was a wooden fence. Two boards were observed to be broken with trash and debris observed between the broken boards 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.
“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. 1 Medicare payment denial on record.
- Medicare payment denial — starting 2024-09-03 for 14 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to INFINITY HEALTHCARE CONSULTING — 69 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 | 2 of 5 | 2.0 | ≈ chain avg |
| Health inspection | 2 of 5 | 2.1 | -0.1 vs chain |
| Staffing | 2 of 5 | 1.5 | +0.5 vs chain |
| Quality measures | 3 of 5 | 3.7 | -0.7 vs chain |
The other 68 homes this chain runs (chain average 2.0★, per CMS)
Showing 40 of 68; 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 |
|---|---|---|---|
| KESLER, HEATHER | Individual | CONTRACTED MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | since 05/19/2014 |
| HORNER, JOHN | Individual | CORPORATE OFFICER | since 05/19/2014 |
| THE WATERS OF INDIANAPOLIS, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 05/19/2014 |
CMS files one row per role, so the 4 rows in the source record cover these 3 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.
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.
About 80% 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 $885K paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Indiana Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 155409. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-26, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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