Brickyard Healthcare -Sycamore Village Care Center
2905 W Sycamore St, Kokomo, IN 46901 · For profit - Corporation · 110 certified beds · (765) 452-5491 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 abuse, neglect, or exploitation citations (F0600, F0602) — most recent Oct 2023
- it has a citation for mishandling residents’ money or property (F0567)
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
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) | 3 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 | 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 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 2.3% | 11.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.6% | 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 | 0.3% | 1.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 20.5% | 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 | 7.4% | 3.9% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 4.5% | 11.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 40.4% | 23.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 96.9% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.7% | 3.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 28.6% | 23.3% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.8% | 13.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.9% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 63.0% | 79.0% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 31.8% | 22.2% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 9.8% | 10.8% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.08 | 1.61 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.16 | 1.44 | 1.80 | 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.
47.0% 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 33 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 45.0% 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 20 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 0.29 therapist hours per resident per day in 2026Q1 — more than 46% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 47.0%CMS range 32.9–62.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.3%CMS range 6.8–16.4 | 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 | 45.0% | 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 | 55.0% | 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 | 30.0% | 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 | 92.9% | 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 | 0.0% | 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 | 6.2%CMS range 3.4–12.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.07 | 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 110 beds and averages 103.0 residents a day — about 94% occupied, or roughly 7 beds typically open. It runs fairly full. 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 3.36 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.82 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.98 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 2.86 hrs/resident/day on weekends vs 3.56 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.96 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 42% 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.
28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.
- 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the kitchen was maintained in a safe and sanitary condition in 1 of 1 kitchen reviewed. This deficient practice had the potential to affect 95 of 95 residents who received food from the kitchen.Findings include:During the kitchen observation, on 1/4/26 at 10:58 a.m., with the Dietary Manager (DM), the following were observed:a. The walk-in refrigerator contained two 16-ounce cans of Pepsi open, two cans of Pepsi not open, one 16-ounce bottle of water opened, a thirty-two-ounce bottle of Coffee Mate French Vanilla liquid creamer with no sugar and a Gordons choice whipped topping. All without a date or label.b. Four empty cardboard boxes were not broken down and stacked on the floor by the back exit door. c. The floor under the serving station had dried unknown food and unopened condiment packets. d. The floor under and around the oven had unknown food substances and grease.e. The floor in the refrigerator had small particles of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-09 · tag F0583 — failed to protect personal privacy — isolatedKeep 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, interview and record review, the facility failed to ensure privacy was provided for a resident during care for 1 of 1 resident randomly reviewed for privacy. (Resident 5)Findings include: During a random observation, on 1/7/26 at 11:21 a.m., RN 9 and QMA 15 entered Resident 5's room to administer medication through the resident's gastrostomy tube (a tube placed through the abdomen directly into the stomach for long-term feeding, hydration, and medication delivery). RN 9 placed the medication on the bedside table and asked QMA 15 to watch the medication while she washed her hands. RN 9 returned and QMA 15 exited the room. RN 9 did not have water to flush the medication and asked the Executive Director (ED) to get a cup of water off the medication cart. The ED brought the water to RN 9 and left the room. Resident 5's door and privacy curtain remained open. RN 9 pulled the resident's covers back, lifted his gown, and exposed his abdomen. The privacy curtain and the door remained open. A visitor in the facility walked by the resident's room and looked inside. 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 · Dcited before2026-01-09 · 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 staff obtained another weight after a documented weight gain for 1 of 3 residents reviewed for quality of care. (Resident 23) Findings include:The clinical record for Resident 23 was reviewed on 1/7/26 at 9:53 a.m. The diagnoses included, but were not limited to, cerebral palsy, conversion disorder with seizure or convulsions, anxiety disorder, hypertension, cognitive communication deficit, and intellectual disabilities. A care plan, dated 6/23/25, indicated Resident 23 triggered for obesity and a body mass index (BMI) greater than 30. Interventions included, but were not limited to, weights according to the physician's order.A clinical record indicated Resident 23 had the following weight:On 7/1/25, the resident's weight was 244.0 pounds. On 8/5/25, the resident's weight was 270.0 pounds. Resident 23 had a significant weight gain of 10.66% in 36 days. There was no documentation located in the medical record to indicate another weight had been obtained to determine if the weight was correct or the physician was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-09 · 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
Based on observation, interview and record review, the facility failed to ensure a resident was kept safe during care and transfers for 1 of 4 residents reviewed for accidents. (Resident C)Findings include:During an interview, on 1/7/26 at 10:39 a.m., Resident C's daughter indicated the resident had fallen twice. The first was from her bed. The resident's bed was smaller than her current bed, she rolled out and fell on the floor during incontinence care. There was only one CNA in the room, and the CNA pushed the resident too hard, and she fell out of her bed. The second was from the mechanical lift. The facility did not call her when the resident's lift strap on the pad broke. The resident called from the ambulance. When the resident was in the emergency room, the Executive Director called but it was at least 30 minutes after the resident was in the emergency room. The Executive Director had asked if she wanted to see the broken pad and then when she asked to see the pad the Executive Director indicated it was no longer available. The clinical record for Resident C was reviewed on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-09 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure medications were dated when opened in 1 of 3 medication carts reviewed for medication storage. (East Hall)Findings include:During an observation, on 1/8/26 at 11:01 a.m., with the Infection Preventionist Nurse, the East Hall medication cart had the following:a. One multi-use tube of Triad Wound paste was not labeled with an open date.b. One multi-use tube of Diclofenac gel 1% was not labeled with an open date.During an interview, on 1/8/26 at 11:06 a.m., the Infection Preventionist Nurse indicated the medications should have been labeled with a date when they were opened.During an interview, on 1/9/26 at 10:52 a.m., RN 3 indicated if a new tube of medication was opened, it would be dated with the date opened and placed in the treatment cart with the residents' other medications.During an interview, on 1/9/26 at 12:46 p.m., Pharmacist 8 indicated she was unsure of the shelf life of Diclofenac gel and Triad Wound paste once opened, but they should be dated when they were opened.A current facility policy,…
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 before2024-12-19 · 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 compromised controlled substance medications were not stored in the medication cart for 2 of 4 medication carts observed for medication storage. (North cart and South cart) Findings include: 1. During an observation, on 12/18/24 at 10:45 a.m., the North medication cart had five compromised controlled substance cards. a. The clinical record for Resident 14 was reviewed on 12/18/24 at 11:35 a.m. The diagnoses included, but were not limited to, insomnia and anxiety disorder A card of quviviq (for insomnia) 25 milligram (mg) tablet for Resident 14 had clear tape covering the back of the number 6 slot. b. The clinical record for Resident 42 was reviewed on 12/18/24 at 11:40 a.m. The diagnoses included, but were not limited to, pain and anxiety. A card of oxycodone (for pain) 10 mg tablet for Resident 42 had a slit on the back of the card in the number 22 slot. A card of alprazolam (for anxiety) 1 mg tablet for Resident 42 had a slit on the back of the card in the number 23 slot. c. The clinical record for…
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 · D2024-12-19 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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 the SNF-ABN (Skilled Nursing Facility-Advanced Beneficiary Notice) forms were accurately completed for 2 of 3 residents discharged from Medicare services and remained in the facility. (Resident 45 and 91) Findings include: 1. The Advance Beneficiary Notice of Non-coverage (ABN) form for Resident 45 was reviewed on 12/13/24 at 2:03 p.m. On 10/8/24, the facility provided Resident 45 the ABN form which indicated their coverage was ending on 10/10/24. The form was blank in response to the options of coverage for physical therapy and occupational therapy. The blank section of the ABN form read as follows: Read this notice to make an informed decision about your care, ask any questions and choose an option below about whether to receive therapy. Check only one box. We cannot do this for you. There were no options chosen for this section of the form. 2. The ABN form for Resident 91 was reviewed on 12/13/24 at 2:03 p.m. On 12/4/24, the facility provided Resident 91 the ABN form which indicated their coverage was ending on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-19 · 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 ensure Preadmission Screening and Record Review (PASARR) evaluations were updated and accurate for 2 of 4 residents reviewed for PASARR. (Resident 95 and 52) Findings include: 1. The clinical record for Resident 95 was reviewed on 12/16/24 at 8:56 a.m. The diagnoses included, but were not limited to, major depressive disorder, post-traumatic distress disorder, insomnia, and anxiety disorder. A PASARR notice of level I screen outcome, dated 10/23/24, indicated a Level II screen was not required. The rational for the determination indicated there was no evidence of a serious mental health condition. The PASARR level I screen indicated major depressive disorder was listed as a current mental health condition and the current mental health medications prescribed were duloxetine and bupropion for depression. The PASARR did not include the diagnoses of anxiety disorder, post-traumatic stress disorder, or insomnia. Physician's orders, dated 11/12/24, indicated Resident 95 was taking Buspirone 5 mg (milligrams) for anxiety disorder…
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 before2024-12-19 · 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 the physician ordered parameters to hold blood pressure medications were followed for 1 of 1 resident reviewed for quality of care. (Resident 87) Finding includes: The clinical record for Resident 87 was reviewed on 12/16/24 at 8:35 a.m. The diagnoses included, but were not limited to, essential primary hypertension, type 2 diabetes mellitus with diabetic chronic kidney disease, chronic kidney disease stage 3, and dementia. A physician's order, dated 5/9/24 and discontinued 12/5/24 at 5:15 p.m., indicated to give diltiazem (a blood pressure medication) by mouth two times a day and to hold the medication for a systolic blood pressure less than 120. A physician's order, dated 12/6/24, indicated to give lisinopril (a blood pressure medication) by mouth one time a day and to hold the medication for a systolic blood pressure less than 120. A Medication Administration Record (MAR), dated October 2024, indicated diltiazem was given on 10/23/24 with a systolic blood pressure of 117. A Medication Administration Record (MAR),…
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 · D2024-12-19 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 an admission weight was obtained for 2 of 5 residents reviewed for nutrition. (Resident D and H) Finding includes: 1. The clinical record for Resident D was reviewed on 12/16/24 at 9:10 a.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus, muscle wasting and atrophy, and chronic heart failure. A weight summary indicated Resident D weighed 284 pounds on 11/11/24. This was the first weight the facility recorded in the electronic medical record (EMR). Resident D was admitted on [DATE]. The resident was not weighed until 5 days after admission. The facility's clinical admission assessment, dated 11/6/24, included a spot to enter the weight. There was no weight entered. 2. The clinical record for Resident H was reviewed on 12/16/24 at 10:45 a.m. The diagnoses included, but were not limited to, muscle wasting and atrophy, essential hypertension, and morbid obesity. A weight summary indicated Resident H weighed 306 pounds on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · D2024-12-19 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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 policy and procedures were followed for medications administered through a gastrostomy tube (g-tube) for 1 of 1 resident reviewed for a gastrostomy tube. (Resident 67) Finding includes: During an observation, on 12/17/24 at 1:58 p.m., Registered Nurse (RN) 5 opened a medication capsule and poured the medicine into an unmeasured cup of water. RN 5 entered Resident 67's room and placed the cup with the medication, a piston (used to delivery medication into the g-tube) and a 10 milliliter (ml) syringe of normal saline solution on the bedside table. She removed the cap of the prefilled normal saline syringe and placed the end of the syringe to the g-tube port. RN 5 pushed the normal saline into the residents g-tube port, then took the larger piston and filled the piston with the medication. She then quickly pushed the medication into the g-tube. The clinical record for Resident 67 was reviewed on 12/13/24 at 11:35 a.m. The diagnoses included, but were not limited to, gastrostomy tube (g-tube) and dysphagia…
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 · D2024-12-19 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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 physician's order, a care plan, a signed consent, and an assessment was obtained prior to the use of side rails for 1 of 7 residents reviewed for accidents. (Resident 95) Finding includes: During an observation and interview, on 12/12/24 at 10:07 a.m., Resident 95 was in his room lying in bed with bilateral side rails attached to the bed. He indicated the side rails were on the bed when he moved in, and he believed the side rails were to keep him from rolling out of the bed. The facility did not have him sign a consent for the use of the side rails. During an observation, on 12/13/24 10:14 a.m., Resident 95 was lying in bed with bilateral side rails attached to the bed. During an observation, on 12/16/24 at 11:31 a.m., Resident 95 was sitting up on the side of his bed with bilateral side rails attached to the bed. The clinical record for Resident 95 was reviewed on 12/16/24 at 8:56 a.m. The diagnoses included, but were not limited to, muscle wasting and atrophy, cellulitis of left lower limb, acquired…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-19 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 pharmaceutical services were obtained and maintained timely to support a resident's healthcare needs for 1 of 5 residents reviewed for pain management. (Resident E) Finding includes: An Indiana Department of Health intake form indicated Resident E was made to detox from his medications. There was no physician's order to stop the medication, and the resident was discharged from the facility without his Multiple Sclerosis (a disease in which the immune system eats away at the protective covering of nerves) medication. The clinical record for Resident E was reviewed on 12/17/24 at 9:15 a.m. The diagnoses included, but were not limited to, Multiple Sclerosis, anxiety disorder, and muscle spasms of back. A Preadmission Screening and Resident Review (PASRR), dated 6/7/24, indicated Resident E would need support from staff to take his medications safely and correctly. A hospital history and physical, dated 6/13/24, indicated Buprenorphine (an opioid…
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 before2024-12-19 · 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
2. During observations, on 12/12/24, 12/13/24, and 12/17/24, no enhanced barrier precautions (EBP) sign was noted outside Resident 61's room per the physician's order. During observations, on 12/18/24 and 12/19/24, both an enhanced barrier precautions and Contact Precaution signs were noted in the hallway outside the resident's door. The clinical record for Resident 61 was reviewed on 12/16/24 at 10:09 a.m. The diagnoses included, but were not limited to, enterocolitis due to clostridium difficile (C-diff), urinary tract infection, retention of urine, and benign prostatic hyperplasia with lower urinary tract symptoms. A current physician's order, dated 8/20/24, indicated enhanced barrier precautions were to be in place and a sign was to be outside the resident's room. A physician's order, initiated on 11/7/24 and completed on 12/7/24, indicated the resident was to be on contact precautions for enterocolitis due to clostridium difficile. A care plan, initiated 8/20/24, indicated Resident 61 required enhanced barrier precautions. Interventions included, but were not limited to, follow…
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 before2023-10-25 · 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
Based on interview and record review, the facility failed to ensure staff were being supervised when a staff member physically kicked a resident in his back for 1 of 3 residents reviewed for abuse. (Resident B) The deficient practice was corrected on 10/15/2023, prior to the start of the survey, and was therefore past noncompliance. Finding includes: An incident report to the Indiana Department of Health indicated a staff member struck Resident B in the back while he was standing next to the medication cart in the facility. The resident complained of back pain, on 10/3/2023, after the kick to his back. The resident was sent to the hospital for evaluation per physician's order, on 10/3/2023. The staff member was suspended when the hospital staff indicated the resident alleged abuse by the staff member. Family was notified and the investigation continued. The resident returned to the facility with no new orders from the hospital and was not admitted to the hospital. The local police department was notified of the abuse allegation. The record for Resident B was reviewed on 10/25/2023…
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 · E2023-10-03 · tag F0567 — failed to protect residents' money held by the home — patternHonor the resident's right to manage his or her financial affairs.
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 notify residents' family representatives prior to staff spending the residents' personal funds for 4 of 4 residents reviewed for protection of resident funds. (Residents B, E, F and D) Findings include: A facility incident report, dated 9/12/23, indicated Unit Manager 10 was utilizing Kohl's cash which was rewarded when purchasing resident items to assist them in spending down their resident accounts. During the investigation, it was discovered Unit Manager 10 had purchased items for 4 residents between 2022-2023 and had received Kohl's cash during the purchases and it was not returned to the residents. 1. The record for Resident B was reviewed on 9/27/23 at 5:02 p.m. Diagnoses included, but were not limited to, anxiety disorder, bipolar disorder, cognitive communication disorder, and depressive disorder. During an interview, on 9/28/23 at 11:49 a.m., the Business Office Manager (BOM) indicated the Social Service Director (SSD) and Unit Manager 10 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.
- Potential for harm · E2023-10-03 · tag F0602 — failed to protect residents from theft of their belongings — patternProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. During an interview, on 9/27/23 at 4:07 p.m., Resident D's family member indicated the BOM gave permission for Unit Manager 10 to use the resident's money to buy clothes for the resident. The facility did not get her consent to spend the money. Unit Manager 10 had spent some of the money for herself. The record for Resident D was reviewed on 9/27/23 at 4:07 p.m. Diagnoses included, but were not limited to, dementia, generalized anxiety disorder, down syndrome, and a communication deficit. An investigation report, dated 9/25/23, indicated Unit Manager 10 made the following purchase, on 8/8/22 at 7:12 p.m.: a. The receipt total was $1,122.32. b. Unit Manager 10's charge card ending in 4201 was charged $300. c. The rest of the bill was paid with the resident's funds totaling $900 in cash. $77.68 was issued in change. d. A total of $200 in Kohl's cash was issued. The $200 [NAME] cash was not returned to the resident. An investigation report, dated 9/25/23, indicated Unit Manager 10 made a purchase which used $900…
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 · E2023-10-03 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure activities were offered daily for 5 of 5 residents reviewed for activities. (Resident 18, 23, 29, 43 and 85) Findings include: 1. During an interview, on 9/28/23 at 1:34 p.m., Resident 18 indicated there had been a volunteer coming in twice a week for bingo. They had not had an Activity Director for months. The record for Resident 18 was reviewed on 9/29/23 at 4:16 p.m. Diagnoses included, but were not limited to, depressive disorder, anxiety disorder, hypertension, and heart failure. A care plan, dated 12/24/19, indicated the resident made their activity interests known. Interventions included, but were not limited to, enjoyed attending group functions such as bingo, trivia, and parties/socials at her discretion. A documentation survey report, for 9/1/23 to 9/28/23, indicated the resident participated in 8 activities marked for dayshift and 3 activities marked for evening shift. 2. During an interview, on 9/28/23 at 1:35 p.m.,…
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 · D2023-10-03 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were dressed in regular clothing like other residents unless their preferences were identified for alternative clothing for 1 of 1 resident reviewed for dignity. (Resident 75) Finding includes: During an observation, on 9/28/23 at 1:15 p.m., Resident 75 was in her room, sitting in her wheelchair. She was wearing a hospital gown and had a blanket covering her legs. During an observation, on 9/28/23 at 3:44 p.m., the resident was in a wheelchair propelling herself in the hallway and common area wearing a hospital gown. The other residents in the facility were observed wearing regular clothing. The record for Resident 75 was reviewed on 9/27/23 at 4:39 p.m. Diagnoses included, but were not limited to, fracture of the right femur (thigh bone), chronic obstructive pulmonary disease, and post-traumatic stress disorder. A resident personal belongings inventory sheet, dated 9/13/23 and signed by the resident, indicated one black…
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 · D2023-10-03 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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
Based on interview and record review, the facility failed to notify the physician of a blood glucose level greater than the physician's call orders for 1 of 1 resident reviewed for notification. (Resident B) Finding includes: The record for Resident B was reviewed on 9/27/23 at 5:02 a.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus and dependence on renal dialysis. A care plan, dated 11/27/20, indicated the resident was at risk for alteration in blood glucose due to diabetes mellitus. The interventions included, but were not limited to, give insulin per order, report abnormal results per parameters/guidelines. A physician's order, dated 9/17/22, indicated to give Lispro (insulin for blood glucose levels) solution 100 unit/ml(milliliter). Inject the insulin as per sliding scale if the blood glucose levels were as follows: a. 150-200 = 1 units. b. 201-250 = 2 units. c. 251-300 = 3 units. d. 301-350 = 4 units. e. 351-400 = 5 units. Call the physician if the blood glucose levels were less than 70 or more than 400. A facility vital sign document 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.
- Potential for harm · D2023-10-03 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to protect the residents' right to be free from verbal abuse for 1 of 1 resident reviewed for abuse. (Resident C) Finding includes: During an interview, on 9/26/23 at 10:07 a.m., Resident C indicated someone had sworn at her and was unsure of who or when. The record for Resident C was reviewed on 9/28/23 at 11:53 a.m. Diagnoses included, but were not limited to, major depressive disorder, heart failure, and vascular dementia. The facility did an investigation on 7/12/23. The investigation included: a. During an interview, on 7/12/23, CNA 4 indicated he was asked for help by 2 other CNAs to assist with care for Resident C. b. During an interview, on 7/12/23, CNA 5 indicated she and CNA 6 got the help of CNA 4 to help provide care for Resident C. She indicated the resident was resistant to care and she heard CNA 4 say shut your old a up. The roommate was not in the room. c. During an interview, on 7/12/23, CNA 6 indicated she asked CNA 4 to help provide care to Resident C. She indicated while providing care she heard CNA 4…
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 · D2023-10-03 · 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 comprehensive care plan was implemented to address a resident's preferences for 1 of 1 resident reviewed for dignity. (Resident 75) Finding includes: During an observation, on 9/28/23 at 3:44 p.m., Resident 75 was in a wheelchair in the common area wearing a hospital gown. The record for Resident 75 was reviewed on 9/27/23 at 4:39 p.m. Diagnoses included, but were not limited to, fracture of the right femur (thigh bone), chronic obstructive pulmonary disease, and post-traumatic stress disorder. A care plan for wearing a hospital gown in the common areas was not located. During an interview, on 9/29/23 at 3:11 p.m., the resident indicated she preferred to wear her own clothes and did not like to wear a gown in the halls. The resident was admitted with one pair of yellow pants, one red shirt, and a pair of white socks. There were no clothes in her room and the staff told her they were down in the laundry being washed. She indicated they had not washed her clothes since she had been there. During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-03 · 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 there was communication between the hospice company and the facility for care provided by the hospice staff for 1 of 1 resident reviewed for hospice. (Resident 73) Findings include: The record for Resident 73 was reviewed on 9/28/23 at 1:23 p.m. Diagnoses included, but were not limited to, traumatic subdural (between the skull and the brain) hemorrhage, dementia with other behavioral disturbance, aphasia (difficulty speaking), senile degeneration of the brain, anxiety disorder, major depressive disorder, and repeated falls. A care plan, dated 12/18/22, indicated the resident was on hospice care related to end of life care. The interventions included, but were not limited to, coordinate care with hospice, keep the family informed of changes in condition, and to notify hospice of any changes in condition or medication changes. A physician's order, dated 3/8/23, indicated hospice. The hospice binder had a CNA visit listed, on 9/22/23. The hospice Certified Nursing Assistant (CNA) care plan, dated 7/27/23, 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.
- Potential for harm · D2023-10-03 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident's contracted fingers/hands were assessed and to provide services for the contractures for 1 of 2 residents reviewed for limited range of motion. (Resident 73) Finding includes: During an observation, on 9/29/23 at 12:18 p.m., Resident 73 was sitting up in bed, with a food tray in front of her and was eating using her hands. The resident's fingers were all pointed to the palms of her hands. The record for Resident 73 was reviewed on 9/28/23 at 1:23 p.m. Diagnoses included, but were not limited to, traumatic subdural (between the skull and the brain) hemorrhage, dementia with other behavioral disturbance, aphasia (difficulty speaking), senile degeneration of the brain, anxiety disorder, major depressive disorder, and repeated falls. A care plan, dated 12/20/22, indicated the resident had difficulty chewing related to her diagnosis of dementia. The resident used assistive devices to aid in feeding herself and still needed…
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 · D2023-10-03 · tag F0725 — failed to have enough nursing staff — isolatedProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide enough staff to prevent low weekend staffing reported in the third quarter to the Pay-Roll Based Journal (PBJ) staffing report and to provide staff to have activities for the residents on the 100 and 200 halls. Findings include: 1. A PBJ staffing report, for the third quarter of 2023, indicated the facility had reported low weekend staffing for the months of April, May, and June. During a resident council meeting, on 9/28/23 at 1:34 p.m., the resident council reported the staff were slow to answer call lights or they would come into the room, turn off the call light, and not come back. The day shift and the evening shift were the worst for getting call lights answered. During an interview, on 10/3/23 at 12:35 p.m., the Executive Director (ED) indicated she did not start working until July 2023 and was not able to address the low weekend staffing as reported on the PBJ report. During an interview, on 10/03/23 at 12:57 p.m., the Director of Nursing Services (DNS) indicated the third quarter staffing was excessively…
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 · D2023-10-03 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
2. The record for Resident J was reviewed on 9/27/23 at 4:19 p.m. Diagnoses included, but were not limited to, Alzheimer's disease, anxiety disorder, cognitive communication deficit, insomnia, anxiety, dementia in other diseases, and psychosis related to dementia and depression. A physician's order, dated 8/23/23, indicated Risperdal (a medication for schizophrenia) 0.5 mg daily for psychosis with dementia. An IDT (interdisciplinary team) note, dated 3/1/23 at 5:55p.m., indicated a new order for Risperdal 0.25 mg (milligrams) was given by the psychiatric nurse practitioner. The resident's husband and hospice were made aware of the new order. The resident would be observed routinely for signs and symptoms of side effects to the medication. AIMs (Abnormal Involuntary Movement scale) assessment completed and would be completed routinely while taking antipsychotic medication. An IDT note, dated 3/29/23 at 2:44 p.m., indicated a new order was given by the psychiatric nurse practitioner to increase the dosage of Risperdal to 0.5 mg at bedtime. Hospice and the resident's husband made aware…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-03 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure a resident who requested dental services had the paperwork completed and was scheduled for the dentist for 1 of 2 residents reviewed for dental. (Resident H) Finding includes: During an observation, on 9/26/23 at 2:23 p.m., Resident H was watching television in her room. She had some missing bottom teeth and no top teeth. Her front bottom teeth were noted to have some yellowish substance from the gums extending up to the teeth. The record for Resident H was reviewed on 9/27/23 at 4:07 p.m. Diagnoses included, but were not limited to, unspecified dementia, chronic obstructive pulmonary disease, cerebral infarction, hemiplegia (paralysis of one side of the body) affecting the right dominant side, dysphagia (difficulty swallowing), and osteoarthritis. A physician's order, dated 4/27/23, indicated the resident may see the podiatrist, dentist, audiologist, ophthalmologist, and optometrist. An application for limited benefit in-facility dental policy was signed by the resident's responsible party on 4/27/23…
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 before2023-10-03 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure staff sanitized their hands during dining service, staff used gloves to touch medications and a resident's Foley (indwelling urinary) catheter was off the floor for 1 of 2 dining rooms observed, 1 of 7 residents observed for medication administration and 1 of 1 resident reviewed for urinary catheters. (Activity Staff 2, Resident M, and Resident 35) Findings include: 1. During a dining observation of the memory care unit, on 9/27/23 at 11: 48 a.m., Activity Staff 2 was observed to assist a resident to cut up the food on her plate and spread her napkin out. Activity Staff 2 then took a clean tray from the food cart and walked into another resident room to assist her to set up her tray. Then Activity Staff 2 picked up the dirty tray from outside the memory care isolation room and put the dirty tray on the dining table which had drinks with some type of red liquid. The drinks had not been used yet. There were also unused condiment packets and a coffee carafe for serving on the same table. Activity Staff 2…
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 BRICKYARD HEALTHCARE — 23 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 | 3 of 5 | 2.7 | +0.3 vs chain |
| Health inspection | 3 of 5 | 2.3 | +0.7 vs chain |
| Staffing | 3 of 5 | 2.4 | +0.6 vs chain |
| Quality measures | 4 of 5 | 4.0 | ≈ chain avg |
The other 22 homes this chain runs (chain average 2.7★, 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 / manager | Type | Role | Since |
|---|---|---|---|
| DYE, KEARY | Individual | CONTRACTED MANAGING EMPLOYEE | since 03/26/2023 |
| ENGELS, ERIN | Individual | CORPORATE DIRECTOR | since 10/25/2014 |
| GENTRY, MARK | Individual | CORPORATE DIRECTOR | since 01/12/2022 |
| STARKEY, TYLER | Individual | CORPORATE DIRECTOR | since 08/01/2020 |
| WAITE, JOHN | Individual | CORPORATE DIRECTOR | since 08/01/2020 |
| WHICKER, TIMOTHY | Individual | CORPORATE DIRECTOR | since 01/12/2022 |
| FENOUGHTY, DEANNA | Individual | CORPORATE OFFICER | since 07/10/2023 |
| GGNSC KOKOMO LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 09/01/2012 |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 78% 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 $589K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Indiana Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 155367. 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 →
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.