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Cloverleaf Of Knightsville

9325 N Crawford St, Knightsville, IN 47857 · For profit - Individual · 102 certified beds · (812) 446-2309 Medicare & Medicaid certified

Call the home — (812) 446-2309 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citations — no harm found (F0740, F0744)
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure 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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1214 E National Ave 100 · (812) 442-2820 · Call to confirm hours
Pharmacy
2150 E National Ave · (812) 443-0466 · Call to confirm hours
Grocery
ALDI0.7 mi
2132 E National Ave · (855) 955-2534 · Call to confirm hours
Park
9692 S Crawford St · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 2 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 3 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased17.3%11.0%15.4%worse
Long-stay residents who lose too much weight13.2%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.2%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.8%1.1%2.0%better
Long-stay residents with depressive symptoms11.6%25.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury4.1%3.9%3.3%worse
Long-stay residents whose ability to walk worsened28.4%11.9%16.1%worse
Long-stay residents on antianxiety or hypnotic medication15.3%23.5%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%95.4%95.3%typical
Long-stay residents with pressure ulcers4.1%3.6%4.7%better
Long-stay residents with worsening bladder/bowel control25.7%23.3%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table29.8%13.6%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.5%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine78.9%79.0%79.4%typical
Short-stay residents rehospitalized after admission27.3%22.2%22.6%worse
Short-stay residents with an outpatient ER visit9.3%10.8%12.0%better
Long-stay hospitalizations per 1,000 resident days1.491.611.67better
Long-stay outpatient ER visits per 1,000 resident days0.591.441.80better

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.

49.9% 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 78 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.9%U.S. median 51.5%
Got home and stayed home
12.2%U.S. median 10.7%
Went back to hospital
35.4%U.S. median 56.6%
Met the expected recovery
0.32U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 35.4% 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 48 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 0.32 therapist hours per resident per day in 2026Q1 — more than 52% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF49.9%CMS range 39.4–59.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.2%CMS range 8.9–16.710.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge35.4%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge31.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge35.4%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened6.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.1%CMS range 3.6–12.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.861.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.77
RN hours/ resident / day
0.57
LPN hours/ resident / day
1.75
Aide hours/ resident / day
3.09
Total nurse hours/ resident / day
0.68
RN hoursweekends
53.7%
Total nursing turnover
14.3%
RN turnover

How full it usually is: this home is certified for 102 beds and averages 78.2 residents a day — about 77% occupied, or roughly 24 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 3.09 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.77 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.75 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 2.77 hrs/resident/day on weekends vs 3.22 on weekdays — 14% thinner on weekends. RN hours go from 0.81 to 0.68 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% 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

3
deficiencies at the latest standard inspection (2026-02-13)
10
at the previous standard inspection (2024-12-18)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

21 citations, most serious first. The 10 most serious are shown; the remaining 11 are one tap away and print in full.

  • Potential for harm · Dcited before2026-02-13 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure safe administration of peritoneal dialysis (a home-based treatment for kidney failure that uses the lining of the abdomen to filter waste and extra fluid from the blood) by staff trained and qualified to administer peritoneal dialysis for 1 of 1 resident reviewed for peritoneal dialysis (Resident 2). Findings include:During an interview, on 2/10/26 at 10:41 a.m., Resident 2 indicated he was on peritoneal dialysis and staff would place him on the dialysis in the evening and would remove it around 8 to 8:30 a.m. the next morning. Resident 2's record was reviewed on 2/12/26 at 3:09 p.m. The profile indicated the resident's diagnoses included, but were not limited to, end stage renal disease (the final permanent stage of chronic kidney disease where kidneys function less than 15% of normal capacity, requiring dialysis or transplant for survival) and dependence on renal dialysis (indicates a chronic, life-sustaining need for mechanical 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-13 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    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 record review and interviews, the facility failed to ensure dementia (a decline in mental ability such as memory, reasoning, and communication) residents' person-centered specific care needs were communicated to facility staff for 2 of 5 residents reviewed for dementia care (Residents 45 and 8). Findings include:1. Resident 45's record was reviewed on 2/10/26 at 2:12 p.m. The profile indicated the resident's diagnoses included, but were not limited to, Alzheimer's disease with late onset (a progressive brain disorder that slowly destroys memory, thinking skills, and eventually the ability to perform daily tasks, with symptoms worsening over time) and dementia with mood disturbance (the emotional changes and behavioral shifts that occur in people with dementia, often resulting from brain damage). A quarterly Minimum Data Set (MDS) assessment, dated 1/28/26, indicated the resident had severe cognitive deficit. A care plan, dated 5/31/25 and revised on 1/16/26, indicated the resident had a diagnosis of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-13 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    A. Based on observation and interview, the facility failed to maintain separation between clean and soiled cleaning mops and cleaning linens for 1 of 1 observation of the laundry room. This practice had the potential to affect 83 of 83 residents residing at the facility. B. Based on observation, interview, and record review, the facility staff failed to ensure they wore gloves during an injection administration and failed to ensure proper hand hygiene was performed during medication administration for 2 of 5 residents reviewed for medication administration (Resident 61 and 26). Findings include:A. On 2/13/26 at 2:00 p.m., during initial observation of the laundry area with the Infection Prevention (IP) nurse and the Director of Nursing (DON), observed clean mopheads and cleaning linens stored on a shelf in the soiled laundry room next to the washing machine. In addition, cleaning linen items were stored on top of a plastic crate with cans of chemicals inside of crate next to the washer. On 2/13/26 at 2:05 p.m., during an interview the IP nurse indicated she had not noticed the clean…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-18 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews, the facility failed to ensure residents were addressed in a dignified manner and the facility failed to ensure a resident was assisted during meal service in a dignified manner for 2 of 3 dining observations. (Residents 56 and 31). Findings include: 1. During the lunch meal observation in the activity dining room, on 12/12/24 at 12:41 p.m., Resident 56 was sitting at a table eating her lunch when CNA 5 addressed the resident as Honey. CNA 5 stated from the opposite table, Honey use your silverware to Resident 56. Resident 56's record was reviewed, on 12/16/24 at 1:48 p.m. The profile indicated the resident's diagnosis included, but were not limited to, unspecified dementia, severe, with anxiety (a person who is experiencing a significant level of cognitive decline where the exact type of dementia is not known, and alongside this cognitive impairment, they are also exhibiting symptoms of anxiety) and cerebral infarction affecting right dominant side (a stroke (cerebral infarction) has occurred in the right hemisphere of the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-18 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to monitor a resident's weight as ordered for 1 of 4 reviewed for nutrition (Resident 59). Finding includes: During an interview, on 12/12/24 at 11:14 a.m., Resident 59 indicated he had some weight loss when he first came to the facility, but he thought his weight had stabilized now. Resident 59's record was reviewed on 12/17/24 at 10:18 a.m. The profile indicated the resident's diagnosis included, but were not limited to, chronic kidney disease, stage 3 (a person has moderate damage to their kidneys where they are not filtering waste effectively, resulting in mild to moderate loss of kidney function), prediabetes (you have a higher-than-normal blood sugar), and repeated falls. An admission Minimum Data Set (MDS) assessment, dated 11/22/24, indicated the resident was cognitively intact and had an admission weight of 210 pounds. A care plan, dated 11/20/24, indicated the resident was at risk for nutritional deficits related to chronic kidney disease stage 3 and prediabetes. Interventions included, but were not limited 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-18 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure a resident's indwelling urinary catheter (a thin, flexible tube that is inserted into the bladder through the urethra to drain urine), drainage bag and tubing were maintained in a manner to prevent contact with the floor for 1 of 2 residents reviewed for urinary catheters (Resident 1). Findings include: During the initial pool observation, on 12/13/24 at 8:50 a.m., Resident 1 was observed in her bed and the bed was in the low position. Her indwelling urinary catheter drainage bag (catheter bag) was observed in contact with the floor. At the same time, the catheter's tubing was observed sitting on the electrical cord for the resident's oxygen concentrator (a medical device that supplies oxygen-enriched air by removing nitrogen from the air around the patient). The electrical cord was observed in contact with the floor. During a random observation, on 12/13/24 at 3:10 p.m., the resident was observed in her bed. The bed was observed in the low position. The resident's catheter bag was observed to be in…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-18 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to assess a resident's condition for complications before and after hemodialysis treatments (a procedure that removes waste products and excess fluid from the blood when the kidneys are no longer functioning properly) which were received at a certified dialysis facility for 1 of 2 residents reviewed for dialysis (Resident 49). Findings include: On 12/12/24 at 11:34 a.m., during observation and interview, Resident 49 indicated when she received hemodialysis on Monday, Wednesday, and Friday. The staff did not check the access site (also known as vascular access, a surgically created opening in the body that allows a patient to receive hemodialysis) in her left arm after returning from dialysis treatment. She indicated when she returned yesterday 12/11/24, the access site bled and soaked through the bandage on her arm. She indicated she changed the bandage using the supplies she had in her room. On 12/13/24 at 3:30 p.m., during observation after…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-18 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure behavior monitoring was completed for 1 of 5 residents reviewed for unnecessary medications (Resident 30). Findings include: Resident 30's record was reviewed on 12/16/24 at 9:36 a.m. The profile indicated the resident's diagnoses included, but were not limited to, alcoholic cirrhosis of the liver with ascities (a condition where the liver is damaged by chronic alcohol consumption and has a buildup of fluid in the abdomen), visual hallucinations (seeing things that are not there), other chorea (a movement disorder that causes involuntary, rapid, and irregular muscle contractions that affect the face, arms, legs, and trunk), anxiety disorder (a mental health condition that causes excessive and persistent feelings of fear, dread, and uneasiness that interfere with daily life), major depressive disorder (a mental health condition that can cause a persistent feeling of sadness, hopelessness, and a lack of interest in activities), and irregular muscle contractions that affect the face, arms, legs, and trunk. A quarterly…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-18 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and record review, the facility failed to ensure a medication error rate of less than 5 percent with an error rate of 21.43 percent for 3 of 4 residents reviewed for medication administration (Residents 169, 14 and 26). Findings include: 1. On 12/17/24 at 7:45 a.m., observed Registered Nurse (RN) 15, prepare and administer medications to Resident (169). Ferrous Sulfate 1 tablet and Klor-Con 1 tablet were removed from medication card and crushed. Medications were then administered to the resident in applesauce. On 12/17/24 at 9:30 a.m., the medical records of Resident 169 were reviewed. The resident was admitted with diagnosis including but not limited to anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells) and hypokalemia (a condition where the level of potassium in your blood is lower than normal). Physician orders included but not limited to administer 1 tablet ferrous sulfate EC (enteric coated) (tablets or capsules with a coating that prevents the medication from dissolving in the stomach and…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-18 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews, the facility failed to ensure medication were labeled properly for 3 of 4 medication carts reviewed for medication storage (Residents 58, 26, and 2). Findings include: On 12/17/25 at 8:00 a.m., medication storage cart A was observed. Tresiba Insulin pen prescribed for Resident 2. Pharmacy dispensed date was 11/14/24. Date opened was not indicated on the insulin pen. On 12/17/24 at 8:20 a.m., medication storage cart 1 was observed. Lantus Insulin pen prescribed for Resident 58. Pharmacy dispensed date was 11/19/24. Date opened was not indicated on the insulin pen. On 12/17/24 at 9:00 a.m., medication storage cart B was observed. Basaglar Insulin pen prescribed for Resident 26. Pharmacy dispensed date was 11/28/24. Date opened was not indicated on the insulin pen. On 12/17/24 at 8:05 a.m., during interview Registered Nurse (RN) 15 indicated insulin pens should be dated when opened and an expiration date added to label. On 12/17/24 at 9:05 a.m., during interview Qualified Medication Aide (QMA) 18 indicated insulin pens should 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · D2024-12-18 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to honor food preferences of 1 of 1 resident reviewed for dietary preferences (Resident 49) Findings include: On 12/12/24 at 11:25 a.m., during observation and interview, Resident 49 indicated she had asked several times not to be served vegetables and the facility continued to put them on her plate. On 12/12/24 at 12:27 p.m., observation of the dietary tray slip of Resident 49 indicated the dietary slip food dislikes did not indicate the resident did not want vegetables. On 12/16/24 at 9:00 a.m., the medical record of Resident 49 was reviewed. The resident was admitted to the facility on [DATE]. Diagnosis included but were not limited to end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life, dependence on renal dialysis (a treatment that filters waste and excess fluid from your 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-18 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure undated and expired foods were disposed of for 1 of 2 kitchen observations. Findings include: During a food storage observation with [NAME] 3 on 12/12/24 at 9:50 a.m., the walk in refrigerator contained a clear plastic container with a lid that had corn, the corn was dated 12/5/24. There was a clear plastic bag of lettuce with a delivery dated 10/31/24, the lettuce was brown and wilted inside the bag. Three cucumbers were found on a shelf in an open and undated plastic bag. During an interview, on 12/12/24 at 9:52 a.m., [NAME] 3 indicated food was good for 3 days once it was opened and placed in a new container. She indicated the corn should have been disposed of by now and the lettuce was no longer good because it was delivered in October and was brown and wilted. She was unsure why they hadn't been disposed of them by now because she was not the person responsible for that. [NAME] 3 indicated food should be labeled once it was delivered to the facility and she had no idea when the cucumbers were…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-18 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to follow the antibiotic stewardship protocol program for 1 of 5 residents reviewed for antibiotics (Resident 46). Findings include: On 12/17/24 11:14 a.m., the medical record of Resident 46 was reviewed. The resident was admitted to the facility with diagnosis of, but not limited to, Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), chronic obstructive pulmonary disease (COPD) (a group of diseases that cause airflow blockage and breathing-related problems), urinary retention (a medical condition that occurs when a person is unable to empty their bladder or has difficulty starting or maintaining a steady urine flow), and history of recurrent urinary tract infections (bacteria in the urine, resulting in an infection). A Physician order, dated 8/31/24, indicated to administer one capsule of Ampicillin 500 mg (milligram) via (by way of) G-tube (a tube that is surgically inserted through the abdomen and into 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-11-03 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY A. Based on observation, interview, and record review, the facility failed to ensure an adequate infection control program was implemented to track the COVID-19 positive and potentially exposed residents which had the potential to effect 68 of 68 residents that reside in the facility. B. Based on observation, interview, and record review, the facility failed to follow infection control precautions, COVID-19 testing protocols, and ensure tracking for a COVID-19 outbreak for 68 of 68 residents reviewed for infection control. Findings include: A. On 11/2/23 at 9:01 a.m., the Infection Prevention Nurse (IP) indicated she was tracking for end dates to remove COVID-19 positive residents from the droplet isolation rooms. Residents would be in isolation for 10 days. She indicated she was given a new policy on 11/1/23 for droplet isolation end dates. Residents who had been exposed to COVID 19, would be in isolation for 10 days as well. The residents would be returning to their rooms once the 10 days of isolation 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-03 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure food was covered when delivered to the units and the facility failed to ensure hand hygiene was completed when assisting residents to eat for 1 of 2 dining observations. Findings include: 1. On 10/30/23 at 11:59 a.m., dietary staff delivered an uncovered meal cart with Residents' trays to the A hall, with uncovered brownies on disposable plates on all of the uncovered meal trays. On 10/30/23 at 12:09 p.m., dietary staff delivered an uncovered meal cart with Residents' trays to the B hall, with uncovered brownies on disposable plates on all of the uncovered meal trays. On 10/30/23 at 12:14 p.m., dietary staff delivered a second uncovered meal cart with Residents' trays to the B hall, with uncovered brownies on disposable plates on all of the uncovered meal trays. On 10/30/23 at 12:36 p.m., dietary staff delivered an uncovered meal cart with Residents' trays to the A hall dining room, with an uncovered plate of food on a meal tray and uncovered brownies on disposable plates on all of the uncovered meal…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-03 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    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 notify the dialysis center nurse of changes of condition related to low blood pressures for 1 of 1 resident reviewed for dialysis (Resident 53). Findings include: On 11/1/23 at 12:10 p.m., Resident 53 was observed in his room sitting on the side of the bed. The resident indicated he was very dizzy and had been vomiting. The resident indicated he had several episodes of dizziness and nausea. On 11/2/23 at 10:09 a.m., the clinical record of Resident 53 was reviewed. The record indicated the resident had diagnoses included but not limited to, end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), type 2 diabetes (a disease that occurs when your blood glucose, also called blood sugar, was too high), heart failure (a condition that develops when your heart doesn't pump enough 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-03 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure nail care was provided to dependent residents for 2 of 24 residents reviewed for activities of daily living (ADL) (daily tasks related to resident care and hygiene) (Residents 121 and 46). Findings include: 1. On 10/31/23 10:57 a.m., Resident 121's fingernails were observed untrimmed with chipped nail polish on all the fingernails and dark debris underneath the nails. On 11/1/23 at 2:44 p.m., Resident 121's fingernails were observed untrimmed with chipped nail polish on all the fingernails and dark debris underneath the nails. On 11/2/23 at 8:12 a.m., Resident 121's fingernails were observed untrimmed with chipped nail polish on all the fingernails and dark debris underneath the nails. On 11/2/23 at 11:25 a.m., Resident 121's fingernails were observed untrimmed with chipped nail polish on all the fingernails and dark debris underneath the nails. On 11/2/23 at 11:29 a.m., Registered Nurse (RN) 16 observed Resident 121's fingernails and indicated the resident's fingernails were too long and needed to 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-03 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    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 pharmacy recommendations were completed for 1 of 5 residents reviewed for unnecessary medications (Resident 11). Finding includes: On 11/1/23 at 11:43 a.m., Resident 11's clinical record was reviewed. The resident's diagnosis included, but were not limited to, osteoarthritis (degeneration of joint cartilage and underlying bone causing pain and stiffness) and pain in the left ankle and joints of the left foot. A current physician's order, dated 2/15/23, indicated Tylenol Tablet (acetaminophen) (pain medication) 325 milligrams (mg), give 650 mg by mouth three times a day related to pain in left ankle and joints of left foot and osteoarthritis. A current physician's order, dated 2/15/23, indicated Tylenol Tablet (acetaminophen) 325 mg, give 2 tablets by mouth every 4 hours as needed for pain/fever. A pharmacy consultation report, dated 4/30/23, indicated Resident 11 had current orders for Acetaminophen recommended the maximum of acetaminophen dose was 4000 mg in 24 hours, but may need to be lower for residents with…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-03 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure 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 expired insulin medications were disposed of properly for 1 of 1 medication rooms reviewed for medication storage (Resident 9), and the facility failed to ensure medications and biologicals were labeled and stored according to policy for 1 of 1 treatment carts and 1 of 1 medication carts observed for medication and biological storage (Resident 46, 34, 10, 8, and 48). Findings include: During an observation of Hall, A medication storage room, on [DATE] at 2:10 p.m., the medication refrigerator had a Lantus Solostar insulin glargine (diabetic insulin injection for blood sugar) 100 units/milliliter (ml), 3 ml prefilled pen for Resident 9. The pen had an opened date of [DATE] with an instruction label to discard unused portion after 28 days. During an observation of the medication cart located on A hall, on [DATE] at 2:45 p.m., the cart had an opened bottle of Gentamicin (antibiotic eye drops) 0.3% eye drops for Resident 46 with no…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-03 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to review and track facility wide antibiotic stewardship for 4 of 12 months reviewed. Findings include: On 11/2/23 at 9:08 a.m., the Infection Preventionist Nurse (IP) indicated there was no documentation of tracking, facility mapping or antibiotic stewardship for the months of October 2022, November 2022, December 2022, nor October 2023. Review of April and May 2023 antibiotic use and infection tracking documentation indicated an increase in residents with urinary tract infections and upper respiratory infections. The IP nurse on 11/3/23 at 9:00 a.m., provided documentation indicating in-services were completed on 6/22/23 for perineal care and hand hygiene. Training record lacked documentation of education in urinary tract infection prevention, upper respiratory infection, and identification of signs and symptoms of infections. The IP nurse could not provide facility antibiotic stewardship policy and procedure. 3.1-18(b)(1)

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-03 · tag F0912 — isolated
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    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 record review, observation, and interview, the facility failed to provide at least 80 square feet per resident in multiple occupancy resident rooms for 2 of 50 resident rooms observed (rooms [ROOM NUMBERS]). Findings include: On 11/03/23 at 12:50 p.m., the Administrator provided a copy of a waiver request letter, dated 10/24/22. The letter indicated a waiver had been requested for rooms [ROOM NUMBERS] of the facility. During a maintenance tour with the Maintenance Director, on 11/03/23 at 12:08 p.m., rooms [ROOM NUMBERS] were measured. The current measurements of the rooms, were as follows: a. room [ROOM NUMBER], licensed for 3 beds, measured 226.2 total square feet. Square footage per resident equaled 75.4 square feet. At the same time, 1 bed was observed in the room. b. room [ROOM NUMBER], licensed for 3 beds, measured 226.2 total square feet. Square footage per resident equaled 75.4 square feet. At the same time, 1 bed was observed in the room. During an interview, on 11/03/23 at 12:11 p.m., the…

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

    Environmental Deficiencies · Waiver has been granted

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to IDE MANAGEMENT GROUP — 10 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.2+0.8 vs chain
Health inspection 4 of 53.2+0.8 vs chain
Staffing 2 of 52.1-0.1 vs chain
Quality measures 2 of 52.9-0.9 vs chain
The other 9 homes this chain runs (chain average 3.2★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
CIBC BANK USAOrganization5% OR GREATER MORTGAGE INTERESTsince 11/01/2020
BORNE-BAUMAN, CANDICEIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2019
FLUECKIGER, RUSSELLIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 07/01/2012
LEHMAN, SCOTTIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 07/14/2020
MACKLIN, LARRYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 07/01/2012
MCINTIRE, DAVIDIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2019
ADAMS COUNTY MEMORIAL HOSPITALOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 07/01/2012
CLOVERLEAF NURSIG AND REHAB LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2020
ABBOTT, ALEXAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2024
JOHNSON, CRAIGIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2020
SMITH, SCOTTIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2020
SPRUNGER, KYLEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2018
WHEELER, DANEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 07/01/2012
GREATOREX, TINAIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 12/29/2025
SCHIOWITZ, MARCIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 12/29/2025
SEBBAG, GABRIELIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 12/29/2025
9245 KNIGHTSVILLE PROPCO LLCOrganizationADP OF THE SNFsince 11/01/2020
ADVANCED CARE CONSULTANTS LLCOrganizationADP OF THE SNFsince 11/01/2020
BLUE MANAGEMENT SERVICES LLCOrganizationADP OF THE SNFsince 01/01/2024
CLINICAL CONSULTING SERVICES LLCOrganizationADP OF THE SNFsince 11/01/2020
FIRST BANK OF BERNEOrganizationADP OF THE SNFsince 01/01/2020
LME FAMILY HOLDINGS LLCOrganizationADP OF THE SNFsince 11/01/2020
SAMARA FAMILY HOLDINGS LLCOrganizationADP OF THE SNFsince 11/01/2020
SUMMATION FINANCIAL SERVICES LLCOrganizationADP OF THE SNFsince 11/01/2020

CMS files one row per role, so the 32 rows in the source record cover these 24 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.

11 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.

$9.2M
Net patient revenuemost recent cost report
+16.0%
Operating marginrevenue minus expenses
$1.2M
Related-party expense16% of expenses
Who pays — share of resident-days
Medicaid 81%Medicare 6%Other / private 13%

About 81% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 16% 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

$292per resident / day
operating cost
$8,883per month
≈ monthly operating cost
$348per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IN

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Indiana Medicaid page.

Typical monthly cost in Indiana
$8,943/mo
Nursing home (semi-private)
$10,326/mo
Nursing home (private)
$5,639/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 155542. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-13, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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