Wildwood Healthcare Center
7301 E 16th St, Indianapolis, IN 46219 · For profit - Corporation · 160 certified beds · (317) 353-1290 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
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2025
- it has 1 actual-harm citation
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
- about 42% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 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 | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 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 improved from 1 to 2 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 | 1.5% | 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 | 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 | 0.9% | 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 | 2.4% | 3.9% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 3.4% | 11.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 21.7% | 23.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.7% | 3.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 18.0% | 23.3% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 17.8% | 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 | 79.6% | 79.0% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 24.5% | 22.2% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 8.4% | 10.8% | 12.0% | better |
‡ 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.
41.3% 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 45 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 52.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 21 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.22 therapist hours per resident per day in 2026Q1 — more than 26% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| 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 | 41.3%CMS range 30.2–53.7 | 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 | 12.1%CMS range 7.8–17.3 | 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 | 52.4% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 47.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 42.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care 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 | 3.2% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 1.57 | 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 160 beds and averages 130.7 residents a day — about 82% occupied, or roughly 29 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 3.51 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.28 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 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 3.09 hrs/resident/day on weekends vs 3.68 on weekdays — 16% thinner on weekends. RN hours go from 0.35 to 0.10 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 43% 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · G2024-05-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement interventions to eliminate and/or reduce a resident's risk of being burned by a therapy modality by not ensuring the maintenance/inspection of a hydrocollater (a temperature controlled water bath for placing heating pads) was up to date, not maintaining a current temperature log for the hydrocollater, not testing the temperature of the hydrocollator prior to use on a resident, and not following the policy and/or procedure for use of a hydrocollator and heat pads resulting in a resident receiving a blistering burn on his hand for 1 of 3 residents reviewed for wounds. (Resident H) Findings include: The clinical record for Resident H was reviewed on 5/22/24 at 1:29 p.m. Resident H's diagnoses included, but not limited to, type II diabetes, anxiety disorder, major depressive disorder, and paranoid schizophrenia. A Quarterly Minimum Data Set ( MDS) dated [DATE] indicated, Resident H was had a moderate cognitive impairment. A Facility…
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 · F2026-01-09 · 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 foods were served in a sanitary and safe manner for 3 of 3 observations. Staff hair was not covered while in the kitchen, food preparation, and serving areas. (Dietary Manager, [NAME] 2, Dietary Aide 3) Findings include: 1. During the initial kitchen tour with the Dietary Manager (DM) on 1/5/26 from 9:10 a.m. to 9:35 a.m., the following was observed: - The DM was observed walking throughout the kitchen area. The DM was observed to have a beard restraint in place that covered above the nose area, below the chin area and approximately 2 inches from the ears. Facial hair, approximately one-fourth inch in length, was observed between the ears and the edge of the beard guard. The facial hair was observed to not be covered. - Dietary Aide 3 was observed walking throughout the kitchen area. Dietary Aide 3 was observed to have facial hair approximately one-fourth inch in length above the upper lip area. The facial hair was observed to not be covered. 2. During a follow-up kitchen observation on 1/5/26 from…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-01-09 · tag F0583 — failed to protect personal privacy — patternKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure private information was kept confidential for 29 of 127 residents that reside in the facility for 3 of 5 days of the survey. (Resident 1, Resident 4, Resident 5, Resident 7, Resident 10, Resident 11, Resident 15, Resident 20, Resident 22, Resident 26, Resident 25, Resident 35, Resident 43, Resident 44, Resident 46, Resident 53, Resident 64, Resident 82, Resident 83, Resident 84, Resident 93, Resident 103, Resident 106, Resident 107, Resident 108, Resident 110, Resident 141, Resident 142, Resident 143)Findings include: On 1/5/26 at 9:35 a.m., white dry erase boards located across from the 400 and 500 hallways' nursing station were observed. The whiteboards, visible to all visitors and other residents, indicated the following resident information by each resident's room number. The specific resident room numbers were listed under the following categories, including but not limited to: -Daily Showers, Day [Showers]: (Resident's specific room number) Resident 93(Resident's specific room number) Resident 11(Resident's…
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 · D2025-04-16 · 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 interview and record review, the facility failed to ensure a resident was administered medications per their policy for 1 of 3 residents reviewed for medication compliance. (Resident B) Findings include: The clinical record for Resident B was reviewed on 4/15/2025 at 1:35 p.m. The medical diagnoses included stroke and heart failure. A Quarterly Minimum Data Set Assessment, dated 2/6/2025, indicated Resident B had moderate cognitive impairment. A heart failure care plan, revised 9/18/2024, indicated Resident B was at risk for complications related to heart failure, and an intervention of administering medications as ordered. During an interview on 4/15/2025 at 1:15 p.m., Resident B indicated a few weeks ago a nurse came into his room and gave him medications which were not his. She put the medications on his bedside table and left. When she was gone, he got out of bed and took the medications up to the night shift supervisor but could not recall her name. The night shift supervisor told him the medications were not his and disposed of them. During an interview on 4/15/2025…
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 before2025-04-16 · 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 observation, interview, and record review, the facility failed to ensure a resident was free from verbal abuse by staff for 1 of 3 residents reviewed for abuse. (Resident D) Findings include: The clinical record for Resident D was reviewed on 4/16/25 at 10:00 a.m. Her diagnoses included, but were not limited to, bipolar disorder, anxiety, depression, and attention deficit disorder. The 2/12/25 Significant Change MDS (Minimum Data Set) Assessment indicated she was cognitively intact. She required partial/moderate assistance for upper body dressing, substantial/maximal assistance for lower body dressing, putting on and taking off footwear, and transferring from the chair to bed. The behavior care plan for Resident D, revised 3/30/25, indicated she had a behavior problem and refused to be checked and changed at times. Resident D and her spouse would panhandle off property at times, would hoard items, refused medications at times, made false statements/allegations, and sought male attention. Interventions included to approach and speak in a calm manner and to honor resident's…
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 · D2024-10-30 · tag F0559 — isolatedHonor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
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 notification and documentation was provided to Resident 23 regarding a room change for 1 of 1 resident reviewed for room change. Findings include: The clinical record for Resident 23 was reviewed on 10/29/2024 at 1:20 p.m. The medical diagnoses included chronic obstructive pulmonary disease. A Significant Change Minimum Data Set Assessment, dated 8/27/2024, indicated Resident 23 was cognitively intact. A census report provided by the Director of Nursing, on 10/30/2024 at 9:45 a.m., indicated Resident 23 moved rooms on 7/1/2024. During an interview and observation on 10/23/2024 at 12:36 p.m., Resident 23 indicated a couple months ago, they were coming back from lunch and their items had been moved from their room to a room across the hall. When they asked the Certified Nurse Aide (CNA), unable to recall CNA name, they were told they were moved across the hall for a little bit so their room could be renovated. Resident 23 stated, I was never told about coming over here [to the new room] before it happened and 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 · D2024-10-30 · 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 accurate care planning of Resident 56's bathing preferences, failed to assist a resident with shaving (Resident 120), and failed to provide nail care (Resident 39) for 3 of 5 residents reviewed for activities of daily living (ADLs). Findings include: 1.) The clinical record for Resident 56 was reviewed on 10/28/2024 at 1:20 p.m. The medical diagnoses included multiple sclerosis. A Quarterly Minimum Data Set (MDS) assessment, dated 8/21/2024, indicated Resident 56 was cognitively intact. A care plan, last revised on 2/5/2024, indicated Resident 56 was dependent on helper for bathing tasks and wished to have showers on Friday mornings. A care plan, last revised on 2/5/2024, indicated Resident 56 was dependent on helper for bathing tasks and wished to have showers on Wednesday and Saturdays. Review of the care tasks, last updated 9/13/2024, indicated Resident 56 was to receive showers on Fridays. During an interview and observation, on 10/24/2024 at 12:45 p.m., Resident 56 indicated they would like 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 · Dcited before2024-10-30 · 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 hold a resident's insulin, as ordered, and ensure a resident had an off-loading cushion in her wheelchair, as care planned, for 1 of 1 resident reviewed for insulin and 1 of 1 resident reviewed for skin integrity. (Residents 11 and 14) Findings include: 1. The clinical record for Resident 11 was reviewed on 10/25/24 at 11:41 a.m. His diagnoses included, but were not limited to, diabetes mellitus. The diabetes care plan for Resident 11, revised 8/18/23, indicated to administer insulin injections per physician orders. The active physician's orders indicated to inject seven units of Humalog (fast acting insulin) solution subcutaneously in the morning with breakfast, in the afternoon with lunch, and in the evening with dinner. The orders indicated to Hold for results less than 100. The October 2024 medication administration record (MAR) indicated his blood sugar was 72 on 10/6/24 at dinner, 87 on 10/7/24 at breakfast, 70 on 10/8/24 at breakfast, 78 on 10/12/24 at breakfast, 96 on 10/16/24 at dinner, 91 on 10/21/24 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 before2024-10-30 · 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 ensure a resident's palm guard was applied, as ordered, and initiate a range of motion (ROM) program for 1 of 3 residents reviewed for positioning and mobility and 1 of 1 resident reviewed for rehabilitation and restorative services. (Residents 99 and 109) Findings include: 1. The clinical record for Resident 109 was reviewed on 10/23/24 at 12:30 p.m. Her diagnoses included, but were not limited to, right side hemiparesis. The activities of daily living (ADLs) care plan, revised 8/19/24, indicated Resident 109 had a self-care performance deficit related to cerebral vascular accident, right side hemiparesis, depression, insomnia, substance abuse, and hypertension. The goal was for her to maintain her current level of function. An intervention was provision of substantial/maximal assistance with upper body dressing. The undated Therapy Referral Restorative nursing form indicated Resident 109 was to participate in the Range of Motion and Splint/Brace Care program to prevent further contracture and maintain…
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 before2024-10-30 · 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
Based on interview and record review, the facility failed to ensure a resident had a care plan to address her individualized needs related to substance use disorder for 1 of 2 residents reviewed for hospitalization. (Resident 93) Findings include: The clinical record for Resident 93 was reviewed on 10/24/24 at 10:30 a.m. Her diagnoses included, but were not limited to, depression and substance use disorder (SUD). The 9/25/24 Quarterly Minimum Data Set (MDS) assessment indicated she was cognitively intact. An interview was conducted with Resident 93 on 10/24/24 at 10:46 a.m. She indicated she smoked weed in the facility in the back area. In December 2023, she smoked a joint outside in the smoking area and then sat in the gazebo. It was her own weed that she smoked, but she and a couple other residents usually put weed together to smoke, so she couldn't say for sure where the weed in the joint she smoked that day came from. Staff kept coming outside but left her in the gazebo throughout the night. Eventually they brought her inside with her rollator walker. Nursing took her blood…
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 before2024-10-30 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 1 of 2 medical storage rooms were free of expired supplies. Findings include: During an observation of the storage room on the 700 hall on [DATE] at 11:50 a.m., with Licensed Practical Nurse (LPN) 5, there were multiple expired items. Items included the following: three packages of twenty-two gauge by one inch BD Insyte Autoguard IV catheter- expired [DATE], five packages of BD Vacutainer push button blood collection set twenty-one gauge by three fourths inch by twelve inch- expired [DATE], nine packages of BD Vacutainer safety-lok blood collection set, twenty-three gauge by three fourths inch by one inch (six expired [DATE] and three expired [DATE]), two packages of Progressive Medical Administration set with flow controller- expired [DATE], and one package of disposable inner cannula for use with tracheotomy tube - expired [DATE]. During an interview with Registered Nurse (RN) 6 on [DATE] at 12:00 p.m., they indicated the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 16 citations
- Potential for harm · Dcited before2024-05-23 · 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 ensure a resident's wound dressing was completed twice a day per physician's order for 1 of 3 residents reviewed for wounds. (Resident T) Findings include: The clinical record for Resident T was reviewed on 5/22/24 at 9:03 a.m. Resident T's diagnoses included, but not limited to, obsessive compulsive disorder, anxiety disorder, schizophrenia, and alcohol-induced dementia. A Quarterly Minimum Data Set (MDS) completed on 5/1/24 indicated, Resident T's cognition was moderately impaired. An interview with Resident T's family member (FM) conducted on 5/21/24 at 10:24 a.m. indicated, Resident T's post surgical follow up notes from the Orthopedic physician indicated that the facility had not been changing Resident T's dressing to the right elbow were not being done twice a day like they were ordered. She stated, she had received a call from the facility on 3/22/24 concerning that Resident T had developed an open area on his left foot's second toe and this was when she had informed the person on the phone that her father…
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 · E2023-09-14 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to maintain the dignity of residents in the facility for 4 of 7 residents reviewed for dignity. (Residents 20, 37, 54, and 64) Findings include: 1. The clinical record for Resident 37 was reviewed on 9/6/23 at 1:45 p.m. Her diagnoses included, but were not limited to, intellectual disabilities, borderline personality disorder, and anxiety disorder. The 8/15/23 Quarterly MDS (Minimum Data Set) assessment indicated Resident 37 had a BIMS (brief interview for mental status) score of 13, indicating she was cognitively intact. An interview was conducted with Resident 37 on 9/6/23 at 1:55 p.m. She indicated one of the CNAs (Certified Nursing Assistants) talk to me crazy, and gave a physical description of the CNA. The CNA accused Resident 37 of always messing around. Resident 37 informed another CNA, CNA 25, about it and stated, I tell her all the time. Resident 37 indicated she told the nurses about it too, and they say she's all right. Resident 37 had not discussed her treatment by this CNA with the social services…
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 before2023-09-14 · tag F0740 — failed to provide behavioral / mental-health care — patternEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a plan of care for a resident with intermittent explosive disorder after a physical altercation with another resident; update a plan of care with new interventions for a resident with intermittent explosive disorder after an incident of verbal aggression against another resident; develop and implement a plan of care, upon admission, for a resident with known active substance use disorder; update and revise a resident's plan of care with individualized new interventions to address his behaviors; and provided a resident his leave of absence medication, including narcotics, in advance, instead of upon leaving the facility, for a resident with a history of physically aggressive behavior related to his narcotic medication for 1 of 4 residents reviewed for abuse and 4 of 5 residents reviewed for behaviors. (Residents 39, 99, 109, 119, and 310). Findings include: 1. The clinical record for Resident 109 was reviewed on 9/12/23 at 10:40…
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 before2023-09-14 · 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 medications stored in the medication carts and medication rooms were labeled with the residents' names, dated with open dates, not expired, and discharged residents' medications removed for 4 of 8 medications carts and 2 of 4 medication rooms observed. (Residents 1, 11, 15, 24, 46, 56, 92, 123, 143, and 351) Findings include: 1. Medication Carts a. An observation was made of a Windsor unit medication cart with Qualified Medication Assistant (QMA) 8 on 9/11/23 at 10:48 a.m. The medication cart was observed included, but was not limited to the following medications: 1 opened Lantus insulin pen - labeled with Resident 11's name, but no opened date on pen 1 opened Humalog insulin pen - labeled with Resident 11's name, but no opened date on pen 1 opened artificial tears bottle- labeled with Resident 46's name, but no opened date on bottle 1 opened prednisolone 1% opthamolic solution bottle- labeled with Resident 46's name, but no opened date on bottle b. An observation was made of a Cambridge South unit…
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 · E2023-09-14 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents by: room curtains not properly hung or torn from hooks, holes in a residents' room wall, a fly strip hanging in a residents room, cracked and discolored ceilings, buckled ceilings in hallway, room thresholds taped down, baseboard not affixed to wall, missing dresser drawer and dried food on walls for residents who reside on the 100, 200, 300, and 700 hallways. Findings include: An environmental tour was conducted on 9/14/23 at 2:06 p.m. with MM (Maintenance Manager), AIT (Administer in training), and ED (Executive Director). During the environmental tour the following observations were made: - Resident 73's and Residents' 96 and 114's rooms had window treatments that were hung properly and/or torn from their hooks - Residents' 116 and 80's room had a hole in the wall large enough to fit a shoe through - Resident 134's room had a sticky, fly strip hanging in his room that he did not place himself - The 00 hallway has two areas were the ceiling…
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 · D2023-09-14 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
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 maintain a resident's dignity regarding possession of medications provided to him by nursing for 1 of 4 residents reviewed for abuse. (Resident 39) Findings include: The clinical record for Resident 39 was reviewed on 9/7/23 at 9:50 a.m. His diagnoses included, but were not limited to: vascular dementia, post-traumatic stress disorder, chronic pain syndrome, and anxiety disorder. The 8/17/23 admission MDS (Minimum Data Set) assessment indicated Resident 39 had a BIMS (brief interview for mental status) score of 13, indicating he was cognitively intact. An interview and observation was conducted with Resident 39 on 9/7/23 at 9:58 a.m. in the smoking area of the facility. He appeared upset while patting his stomach with his hands and indicated he felt assaulted by LPN (Licensed Practical Nurse) 5, who was also in the smoking area at this time. He was pointing at LPN 5, who was assisting another resident in the smoking area. He indicated it happened last Saturday, 9/2/23, and he told everyone about it and filed…
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 before2023-09-14 · 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 interviews and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for 1 of 4 residents reviewed for abuse (Residents 119). Findings include: 1 a. The clinical record for Resident 119 was reviewed on 9/12/23 at 10:29 a.m. The Resident's diagnosis included, but were not limited to, intermittent explosive disorder and depression. A Quarterly MDS (Minimum Data Set) Assessment, completed 6/26/23, indicated he was cognitively intact. A care plan, initiated 5/30/23, indicated Resident 119 had a behavior problem of losing his temper easily, banging his arm on the desk, alcohol use, and verbal aggression. The goal was for him to have fewer episodes of behaviors. The interventions, initiated 5/30/23, were to administer his medication as ordered, approach and speak in a calm manor, behavioral health consults as needed, communicate with resident and resident representative regarding behaviors and treatment, encourage him to express his feelings, intervene as necessary to protect the rights and safety of others, monitor…
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 · D2023-09-14 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a resident's facility-initiated discharge information was conveyed to the resident/resident representative and the discharge summary contained a complete recapitualization of the resident's stay, a final summary of the resident's status, the efforts to assist the resident in locating a continuing care provider, and the reconciliation of medications for 1 of 3 residents reviewed for discharge. (Resident 348) Findings include: The clinical record for Resident 348 was reviewed on 9/13/23 at 10:21 a.m. Resident 348's diagnoses included, but not limited to, metabolic encephalopathy (an issue in the brain caused by a chemical imbalance related to an illness or organs that are not working as well as they should) and alcoholic cirrhosis of the liver (liver damage). An admission MDS (minimum data set) dated 7/22/23 indicated, Resident 348 was cognitively intact and could make medical decisions himself. A letter from Resident 348's insurance company dated 7/25/23 indicated, Resident 348's rehabilitation needs could be met 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 · D2023-09-14 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman at the same time the notice was provided to the resident and/or resident representative for 1 of 3 residents reviewed for discharge. (Resident 348) Findings include: The clinical record for Resident 348 was reviewed on 9/13/23 at 10:21 a.m. Resident 348's diagnoses included, but not limited to, metabolic encephalopathy (an issue in the brain caused by a chemical imbalance related to an illness or organs that are not working as well as they should) and alcoholic cirrhosis of the liver (liver damage). An admission MDS (minimum data set) dated 7/22/23 indicated, Resident 348 was cognitively intact and could make medical decisions themselves. A letter from Resident 348's insurance company dated 7/25/23 indicated, Resident 348's rehabilitation needs could be met at a lower level of care and for that reason any further skilled nursing facility (SNF) care was not medically necessary. A Service Note…
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 · D2023-09-14 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 accurately complete a Preadmission Screening and Resident Review (PASRR) level I for 2 of 2 residents PASRR reviewed. (Resident 64 and Resident 82) Findings include: 1. The clinical record for Resident 64 was reviewed on 9/13/23 at 8:50 a.m. The resident's diagnoses included, but were not limited to, post-traumatic stress disorder, major depressive disorder and cocaine abuse. The resident's admission date was 11/24/21. A PASRR level I screening dated 12/8/21 indicated the resident did not have a substance abuse disorder. An interview was conducted with Social Services Director 1 on 9/13/23 at 1:39 p.m. She indicated the resident's cocaine diagnosis in error was not included on the level 1 screening that was completed on 12/8/21. 2. The clinical record for Resident 82 was reviewed on 9/13/23 at 2:11 p.m. The resident's diagnoses included, but were not limited to, crohn's disease and schizophrenia. The resident's admission date was 6/30/20. A PASRR level I screening dated 11/3/20 indicated the resident did not have a mental…
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 · D2023-09-14 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a resident had care plans to address her dementia, edema, and hypertension for 1 of 33 residents reviewed for care plan creation. (Resident 41) Findings include: The clinical record for Resident 41 was reviewed on 9/8/23 at 2:43 p.m. Her diagnoses included, but were not limited to: vascular dementia, hypertension, heart failure, and edema. The Diagnosis Information section on Resident 41's admission Record tab from the electronic health record indicated diagnoses of acute pulmonary edema, vascular dementia, and hypertension, all with onset dates of 1/23/23. The physician's orders indicated she was to receive one 5 mg tablet of Amlodipine every morning for hypertension, starting 6/1/23; one 25 mg tablet of Carvedilol every morning and at bedtime for hypertension, starting 5/31/23; and one 20 mg tablet of Furosemide in the morning for edema, starting 1/24/23. Review of Resident 41's care plans indicated no care plans to address her dementia, hypertension, or edema. An interview was conducted with 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 · D2023-09-14 · 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 interview and record review, the facility failed to ensure a resident's care plan was reviewed and revised quarterly and/or with significant changes in care by the interdisciplinary team and to the extent practicable, the participation of the resident and/or resident's representative for 1 of 1 resident reviewed for care planning (Resident 14). Findings include: The clinical record for Resident 14 was reviewed on 9/11/23 at 3:18 a.m. The Resident's diagnosis included, but were not limited to, diabetes. A Quarterly MDS (Minimum Data Set) Assessment, completed 8/16/23, indicated she was cognitively intact. During an interview on 9/6/23 at 3:04 p.m., Resident 14 indicated she had not attended an interdisciplinary care plan meeting for awhile. The clinical record did not contain any interdisciplinary care plan notes since 9/28/22. During an interview on 9/11/23 at 3:47 p.m., SSD (Social Services) 2 indicated, if a care plan meeting had been scheduled and/or conducted, the care plan meeting notes would be in the EHR (Electronic Health Record) under the progress notes section.…
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 before2023-09-14 · 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 ensure an orthotic (splint) hand device was provided for 1 of 1 residents reviewed for range of motion. (Resident 47) Findings include: The clinical record for Resident 47 was reviewed on 9/6/23 at 2:40 p.m. The resident's diagnosis included, but was not limited to, stroke. Observations were made of Resident 47 on 9/6/23 at 2:50 a.m. and 9/13/23 at 12:03 p.m. The resident's left hand was not observed with a orthotic device. An observation was made of Resident 47 with License Practical Nurse (LPN) 10 on 9/14/23 at 1:30 p.m. The resident was observed with no orthotic device on her left hand. An interview was conducted with LPN 50 on 9/14/23 at 1:35 p.m. She indicated the resident's clinical record did not indicate the resident had an order to wear an orthotic device. She does not receive restorative services to provide range of motion exercises. An Occupational Therapy Discharge Summary for Resident 47 dated 7/25/22 indicated the resident was to wear an orthotic device daily for contracture management. A therapy…
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 · D2023-09-14 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to honor food choices of a resident for 1 of 1 resident reviewed for choices (Resident 89). Findings include: The clinical record for Resident 89 was reviewed on 9/6/23 at 1:17 p.m. The Resident's diagnosis included, but were not limited to, diabetes. A Quarterly MDS (Minimum Data Set Assessment), completed 8/4/23, indicated Resident 89 was cognitively intact. On 9/6/23 at 1:17 p.m., Resident 89 was observed sitting in his room with his lunch tray on his bedside table in front of him, with a meal ticket on the tray that listed dislikes as pork, beef, and grilled cheese and to send chicken, fish, or turkey, chef salad instead. CNA (Certified Nursing Assistant) 30 entered the room to pick up Resident 89's lunch tray. CNA 30 took the lid off of the tray and asked Resident 89 if he was finished. Resident 89 asked CNA 30 why his ravioli did not come with any sauce on it. CNA 30 indicated the sauce had meat in it and offered a substitute of a cheeseburger or grilled cheese. Resident 89 declined the offered…
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 · D2023-09-14 · 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, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and prevent the transmission of communicable diseases and infections by not disposing of a lancet properly, wearing gloves when administering insulin, using only one alcohol pad to cleanse two different locations for subcutaneous injections, and not performing hand hygiene after removal of gloves for 1 of 2 residents observed during medication administration (Resident 59) and 1 of 2 residents reviewed for transmission-based precautions (Resident 2). Findings included: 1. An observation of Resident 2's room was conducted on 9/7/23 at 2:48 p.m. Resident 2's room had two signs on her door. One sign indicated the room was under contact precautions-droplet isolation (yellow stop-light sign) and the other sign indicated contact precautions. The door also had an isolation station hanging on the door with personal protection equipment (PPE) stored in it. During the observation, HSK (housekeeper) was preparing 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 · D2023-09-14 · 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 observation, interview, and record review, the facility failed to ensure residents extinguished cigarettes in proper receptacles. This had a potential to affect 64 of 64 residents that smoke. Findings include: Observations were made of the designated smoking area in the courtyard on 9/07/23 at 10:52 a.m., 9/11/23 at 9:30 a.m., and 9/11/23 at 7:52 p.m. The courtyard was observed with multiple cigarette butts all over the ground. An observation was made of the smoking area in the courtyard with the Executive Director on 9/13/23 at 1:51 p.m. There were multiple cigarette butts observed all over the ground in the courtyard. There were ashtrays observed on the porch and in the gazebo. An interview was conducted with the Executive Director on 9/13/23 at 2:00 p.m. He indicated the staff sweep up the cigarette butts several times a day. A smoking guidelines policy was provided by the Executive Director on 9/12/23 at 9:00 a.m. It indicated .It is the policy of this facility to promote resident centered care by providing a safe smoking area for residents that request to smoke and are…
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 COMMUNICARE HEALTH — 110 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.2 | -1.2 vs chain |
| Health inspection | 3 of 5 | 2.7 | +0.3 vs chain |
| Staffing | 1 of 5 | 2.6 | -1.6 vs chain |
| Quality measures | 4 of 5 | 4.5 | -0.5 vs chain |
The other 109 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 109; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| HANCOCK REGIONAL HOSPITAL | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/01/2014 |
| LONG, STEVEN | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 08/01/2014 |
| BOND, MARIA | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 07/01/2021 |
| CLARK, TIMOTHY | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/01/2014 |
| DAUGHERTY, JOSHUA | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/01/2020 |
| FELKER, DEAN | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/01/2014 |
| JOYNER, SARA | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/01/2022 |
| WILLARD, LACEY | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 07/01/2022 |
| WILSON, ROY | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/01/2014 |
| SIXTEENTH MGT CO LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2017 |
| DURHAM-BORING, TAMMY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2017 |
| ODENTHAL, RICHARD | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 09/01/2017 |
| PEAK, ETHAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/15/2018 |
| OMEGA HEALTHCARE INVESTORS INC | Organization | ADP OF THE SNF | — | since 09/01/2017 |
| OMG IN MSTR LSCO LLC | Organization | ADP OF THE SNF | — | since 12/01/2025 |
CMS files one row per role, so the 27 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.
4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 88% 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 $9.6M paid to related parties — landlords or management companies under common ownership — equal to about 42% 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 2024. 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, FY2024). 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 155334. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-09, 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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