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Envive Of Lawrenceburg

403 Bielby Rd, Lawrenceburg, IN 47025 · For profit - Limited Liability company · 100 certified beds · (812) 537-1132 Medicare & Medicaid certified

Call the home — (812) 537-1132 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0610) — cited Aug 20242 actual-harm citations1 Medicare payment denial
Insights

The public record raises real questions here. Weigh the concerns below carefully.

Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • about 20% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
368 Bielby Rd Ste 100 · (812) 537-5772 · Call to confirm hours
Pharmacy
281 Bielby Rd · (812) 539-3300 · Call to confirm hours
Grocery
16923 Scenic Dr · (812) 537-9730 · Call to confirm hours
Park
99 Oelker Dr · Typically dawn to dusk
Place of worship
1000 Fairview Dr · (812) 537-1846

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 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.

Overall rating3★
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 increased14.0%11.0%15.4%typical
Long-stay residents who lose too much weight8.1%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.6%0.4%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%1.1%2.0%better
Long-stay residents with depressive symptoms58.8%25.2%6.5%worse 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 injury5.5%3.9%3.3%worse
Long-stay residents whose ability to walk worsened21.1%11.9%16.1%worse
Long-stay residents on antianxiety or hypnotic medication29.0%23.5%18.9%worse
Long-stay residents given the seasonal flu vaccine70.5%95.4%95.3%worse
Long-stay residents with pressure ulcers5.6%3.6%4.7%worse
Long-stay residents with worsening bladder/bowel control17.0%23.3%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table24.2%13.6%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.8%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine52.1%79.0%79.4%worse
Short-stay residents rehospitalized after admission17.0%22.2%22.6%better
Short-stay residents with an outpatient ER visit3.1%10.8%12.0%better
Long-stay hospitalizations per 1,000 resident days1.991.611.67worse
Long-stay outpatient ER visits per 1,000 resident days0.981.441.80better

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.

11.1%U.S. median 10.7%
Went back to hospital
63.0%U.S. median 56.6%
Met the expected recovery
<0.01U.S. median 0.31
Therapy hours / resident / day
<0.01hours / resident / day
Occupational therapy

Met the expected recovery: 63.0% 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 27 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 <0.01 therapist hours per resident per day in 2026Q1 — more than 0% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.1%CMS range 7.1–16.610.7%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 discharge63.0%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 discharge55.6%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 discharge51.9%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 identified88.9%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 dischargenot 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 stay5.6%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 worsened0.0%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 hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.121.02Oct 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

0.62
RN hours/ resident / day
0.87
LPN hours/ resident / day
1.90
Aide hours/ resident / day
3.39
Total nurse hours/ resident / day
0.28
RN hoursweekends
36.7%
Total nursing turnover
12.5%
RN turnover

How full it usually is: this home is certified for 100 beds and averages 59.8 residents a day — about 60% occupied, or roughly 40 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.39 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.62 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.90 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.10 hrs/resident/day on weekends vs 3.51 on weekdays — 12% thinner on weekends. RN hours go from 0.75 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 37% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

6
deficiencies at the latest standard inspection (2026-02-20)
5
at the previous standard inspection (2025-03-17)

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

Inspection deficiencies

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

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.

24 citations, most serious first. The 12 most serious are shown; the remaining 12 are one tap away and print in full.

  • Actual harm · Gcited before2025-09-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 record review and interview the facility failed to provide appropriate assistance to prevent an avoidable accident for 1 of 3 residents reviewed for accidents hazards. This deficient practice resulted in the resident acquiring right medial and right posterior orbital fractures. (Resident D) Findings include:The clinical record for Resident D was reviewed on 9/22/2025 at 3:15 P.M. An admission Minimum Data Set (MDS) assessment, dated 9/3/2025, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, heart failure, asthma, and respiratory failure. The Resident required maximal assistance to transferring from lying to sitting and sitting to standing.The At Risk for Falls Care Plan, dated 8/27/25 and revised on 9/8/25, indicated the resident will be free of falls. The interventions included, but were not limited to, dated 8/27/25, anticipate and meet the resident's needs; and, dated 9/6/25, resident's room closer to nurses station for closer monitoring.The Physical Therapy Progress Report, dated 8/23/25, indicated the resident…

    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
  • Actual harm · Gcited before2023-08-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to transfer a resident, that required a full body mechanical lift, safely using the appropriate lift resulting in a fracture for 1 of 3 residents reviewed for accidents. (Resident C) Findings include: On 8/9/23 at 11:08 a.m., the Director of Nursing (DON) indicated on 7/27/23 Resident C was being assisted into bed with a lift. The resident yelled out in pain and was sent out to the emergency room (ER). The resident had a fractured left fibula and a follow up appointment with Orthopedics. During an observation and interview on 8/9/23 at 1:57 p.m., Resident C was lying in her bed, her left leg was wrapped and elevated on a pillow. She indicated she required a full body mechanical lift for transfers. On 7/27/23, the day of the incident, she was in the wheelchair for a long time and had asked to be put to bed. The full body mechanical lift had quit working. The staff couldn't find a cord to charge it, so they use a standing aid transfer system…

    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 · Ecited before2026-02-20 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    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 follow the physicians' orders related to hold parameters for cardiac medications for 2 of 16 residents reviewed for quality of care. (Residents 37 and 63)Findings include:1. Resident 37's clinical record was reviewed on 02/18/2026 at 2:24 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 11/26/2025, indicated the resident's diagnoses included, but were not limited to, Cancer and Adverse Effects of Antineoplastic (agents, drugs, or therapies that inhibit or prevent the development maturation, or spread of caner/tumor cells) and Immunosuppressive Drugs. The resident's current physician's orders included an open-ended order, with a start date of 12/02/2025, for midodrine (a medication used to treat low blood pressure) 5 mg (milligrams) with meals for hypotension. The medication was to be held if the resident's Systolic Blood Pressure (SBP; the top number) was greater than 120. The December 2025, January 2026, and February 2026 Electronic Medication Administration Records (EMAR) indicated the medication 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-20 · tag F0627 — isolated
    Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
    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 appropriate transfer or discharge documentation was provided for 2 of 3 residents reviewed for transfer or discharge. (Residents 66 and 68)Findings include: 1. The clinical record for Resident 68 was reviewed on 02/19/2026 at 11:00 A.M. A Comprehensive Minimum Data Set (MDS) assessment, accepted on 11/17/2025, indicated the resident admitted to the facility from a short-term hospital stay on 11/03/2025 for care after experiencing a stroke. A Social Services Note, dated 11/21/2025 at 3:49 P.M., indicated the resident was accepted at a different long term care facility. The receiving facility would pick her up on 11/24/2025. The resident's census page in her Electronic Health Record (EHR) indicated she was discharged from the facility on 11/24/2025. During an interview, on 02/20/2026 at 1:34 P.M., Licensed Practical Nurse (LPN) 4 indicated when a resident was discharged from the facility, staff were to complete a discharge summary in the computer that recapped the resident's stay and provided information about 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 · D2026-02-20 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to provide a bed hold for a resident sent to the hospital for 1 of 3 residents reviewed for discharge. (Resident 66)Findings include:The clinical record for Resident 66 was reviewed on 02/19/2026 at 10:42 A.M. A Quarterly MDS assessment, dated 11/13/2025, indicated the resident was cognitively intact. The resident's diagnosis included, but was not limited to, heart failure (a chronic progressive condition where the heart muscle cannot pump enough blood to meet the body's needs for oxygen and nutrients). A Progress Note, dated 11/14/2025 at 7:00 P.M., indicated the resident's family member had requested the resident be sent to the emergency room. The resident was sent to the local hospital per the request. A Progress Note, dated 11/14/2025 at 10:00 P.M., indicated the resident was admitted to the hospital for heart failure.The clinical record lacked the resident receiving a bed hold policy with the discharged . During an interview, on 02/20/2026 1:39 P.M., the Director of Nursing (DON) indicated when a resident went to 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 · Dcited before2026-02-20 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to follow the physicians' orders related to daily weights for 1 of 1 residents reviewed for Hydration Status. (Resident 52)Finding included:The clinical record for Resident 52 was reviewed on 02/19/2026 at 11:21 A.M. An admission MDS assessment, dated 01/12/2026, indicated the resident was cognitively intact. The resident's diagnosis included but was not limited to, metabolic encephalopathy (brain dysfunction caused by chemical imbalances, systemic illness, or organ failure).A physician's order, dated 01/31/2026 through 02/11/2026, indicated the resident was to be weighed daily in the morning for fluid retention. An open-ended physician's order, with a start date of 02/12/2026, indicated the resident was to be weighed daily for fluid retention. The Vitals Record and February 2026 EMAR lacked documented weights for the resident for the following dates: 02/02/2026 through 02/09/2026; 02/08/2026, 02/12/2026, 02/13/2026, 02/15/2026, 02/16/2026, 02/18/2026, and 02/19/2026. During an interview, on 02/20/2026 at 10:11 A.M., QMA 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-20 · 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 observation, interview, and record review, the facility failed to store medications appropriately for 1 of 4 medication carts reviewed and 1 of 3 medication rooms reviewed. (South Medication Cart on the third floor and third floor Medication Room) Findings include: 1. On 02/20/2026 at 9:39 A.M., the South Medication Cart on the third floor was observed with Qualified Medication Aide (QMA) 2 and contained the following: - A small round white pill was lying loose in the bottom of the second drawer along with dust and paper debris,- A small round white pill was lying loose in the bottom of the third drawer along with dust and several pieces of paper debris. During an interview at the time of the observation, QMA 2 indicated she was unaware of what the pills were or who they belonged to. There shouldn't be any loose pills in the medication cart. The current Medication Labeling and Storage policy, dated 8/2024, was provided by Corporate Support Staff (CSS) 5 on 02/20/2026 at 2:04 P.M. The policy indicated, .Medications and biologicals are stored in the packaging, containers, or…

    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 before2026-02-20 · 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

    Based on observation, interview, and record review, the facility failed to follow infection control guidelines related to Enhanced Barrier Precautions (EBP) for 1 of 16 residents reviewed for infection control. (Resident 63)Findings include:During an observation, on 02/19/2026 at 10:58 A.M., Licensed Practical Nurse 3 gathered supplies from a treatment cart and entered Resident 63's room. She sanitized her hands and donned gloves. She then provided wound treatment care to the resident. There was no gown donned prior to or during the wound treatment. There was no indication outside or inside the resident room that they were on EBP. The clinical record for Resident 63 was reviewed on 02/19/2026 at 11:49 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 01/19/2026, indicated the resident was cognitively intact. The resident's diagnoses included but were not limited to, anemia, hypertension, renal insufficiency, diabetes, anxiety, depression, cirrhosis of liver, and liver transplant status. A Wound Nurse Practitioner Report, dated 02/03/2026, indicated the resident had…

    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 · D2025-09-22 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    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 provide adequate equipment to allow residents to call for assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from the residents bedside for 1 of 3 residents reviewed. (Resident C) Findings include:During an interview, on 9/22/2025 at 9:08 A.M., Resident C indicated he had no call light available. When Resident C moved into his room Maintenance came in, and he told the resident there was no spot to hook a call light up. He had been in the room for a few months, and had never received a call light. The facility provided a bell to ring, but he was unable to find it anymore. When he did have access to the bell staff were never able to hear it no matter how much he rang because he was located at the last room at the end of the hallway. Usually if he needed someone he would go into the bathroom and use the call light in there. There was one night he was unable to get out of bed, and needed to vomit and he had to yell out for help because he…

    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 · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-19 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to maintain a functional, sanitary and comfortable homelike environment related to dripping and pooling water. This deficent practice had the potiential to affect 49 of 49 residents residing in the facility. Findings include: The first-floor dining room was observed on 06/19/25 at 8:32 A.M. The door was left open to the first-floor main hallway. The exterior wall had a large window, with a heating and air conditioning unit below the window in the center of the wall. Above the window unit on the ceiling, an area, approximately four feet long and three feet wide, was covered with a black spotted substance with brown staining all around the center, and visible moisture. A brown liquid substance dripped in three separate spots on the floor leaving half dollar sized brown stains on the floor. The stained ceiling was concaved outward, bowing down towards the floor. During an interview, on 06/19/25 at 11:03 A.M., Qualified Medication Aide (QMA) 1 indicated she had noticed the spot on the ceiling in April or May but didn't go in 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 · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-03-17 · tag F0761 — failed to label and store drugs safely — pattern
    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 observation, interview, and record review, the facility failed to store medications appropriately related to labeling medications, cleanliness of medication carts, loose pills, discontinued medications, and expired medications for 2 of 3 Medication Carts reviewed (South Medication Cart on the third floor, North Medication Cart on the second floor) and 1 of 2 Medication Storage areas reviewed (First floor). Findings include: 1. The South Mediation Cart on the third floor was observed on 03/17/25 at 9:59 A.M., with Licensed Practical Nurse (LPN) 4 and contained the following: - An Albuterol inhaler, prescribed on 09/19/24, for Resident 12 , with no open date, - A small side drawer containing bottled liquid medications with a shiny film covering the bottom of the drawer, - One medium round white loose pill, - One small oval white loose pill, and The following cards of discontinued medications: - Cephalexin, an antibiotic, 500 milligrams (mg), 3 pills left, for Resident 13, - Guaifenesin, an expectorant, 600 mg, 3 pills left, for Resident 37, - Cefdinir, an antibiotic, 300 mg,…

    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 before2025-03-17 · 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 observation, interview, and record review, the facility failed to follow the manufacturer's guidelines related to insulin pen usage for 1 of 5 residents observed for medication administration. (Resident 12) Findings include: During an interview and observation with RN 7, on 03/12/25 at 11:13 A.M., medication administration was observed. The nurse prepared insulin for Resident 12 using an insulin pen. RN 7 indicated the resident was to receive 4 units of Aspart/Novolog insulin scheduled with meals and 6 units per the sliding scale, for a total of 10 units. The nurse removed the insulin pen from the medication cart, checked the label, removed the pen cap, cleaned the end of the pen with an alcohol wipe, applied the needle, and removed the cap of the needle. She turned the pen dose selector to two units, primed the pen holding the pen tip facing the floor, squirted out the two units of insulin, turned the pen dose selector to 10 units, donned gloves, and went into the resident's room. The nurse administered the insulin into the resident's abdomen. During an interview with RN…

    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
Show the remaining 12 citations
  • Potential for harm · Dcited before2025-03-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 an accident hazard was thoroughly investigated after a resident acquired a fracture and laceration to her thumb for 1 of 3 residents reviewed for accident hazards. (Resident 13) Findings include: The clinical record for Resident 13 was reviewed on 03/12/25 at 3:04 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 02/10/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, a fracture of the left ilium, seizure disorder, anxiety, and severe intellectual disabilities. A Progress Note, dated 03/01/25 at 12:54 A.M., indicated Licensed Practical Nurse (LPN) 2 entered the resident's room and the resident was observed to have a laceration to her left thumb and the nail bed was red and discolored. During an interview, on 03/12/25 at 10:59 A.M., RN 7 indicated the resident could get herself in and out of her wheelchair, would crawl on the floor, and could only say a few simple words. During an observation, on 03/13/25 at 10:55 A.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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-17 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide 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 observation, interview, and record review, the facility failed to provide physician ordered nutritional supplements for 1 of 2 residents reviewed for nutrition. (Resident 29) Findings include: On 03/12/25 at 3:24 P.M., Resident 29 was observed in the Activity Room participating in an ice cream activity. The resident was very thin in appearance. The clinical record was reviewed on 03/12/25 at 2:58 P.M. The resident was admitted to the facility on [DATE]. A Quarterly Minimum Data Set (MDS) assessment, dated 02/20/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, depression, anxiety, cardiac arrhythmia, and malnutrition. The resident was 72 inches tall, weighed 105 pounds, and was on a physician prescribed weight gain program. The admission MDS assessment, dated 11/11/24, indicated the resident had a diagnosis of malnutrition, was 72 inches tall, and weighed 113 pounds. The current Nutrition Care Plan, with an initiated date of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-17 · 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

    Based on observation and interview, the facility failed to follow appropriate infection control guidelines during medication administration related to hand hygiene for 2 of 5 residents observed. (Residents 28 and 18) Findings include: Medication administration was observed on 03/12/25 at 9:05 A.M., with Qualified Medication Aide (QMA) 8. The QMA prepared a cup of medications and a cup of water for Resident 3. She passed the cups back and forth while assisting the resident, went back to the computer on the medication cart, touched the keys on the computer, then used hand sanitizer. The QMA proceeded to prepare medications for Resident 28, retrieving medications from the cart and documenting on the computer. She prepared a cup of medications, took the medications into the resident's room, donned gloves, administered eye drops, removed her gloves, took the cup of medications back out to the medication cart, and crushed them. She mixed the medications with a spoonful of applesauce, entered the resident's room and assisted the resident with their medications by spooning the mixture into…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-02 · 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 and interview, the facility failed to store food appropriately for 1 of 2 kitchen observations. Findings include: During an observation on 10/02/24 at 9:40 A.M., of the facilities kitchen refrigerators and dry storage the following was observed: - an undated, sealed gallon sized bag half full of cooked ham, - an undated, sealed gallon sized bag half full of cooked taco meat, - a square lidded container, approximately quart sized, filled with country gravy with a prepared date of 09/27/24, and a discard date of 08/01/24, - an undated resident's left over pizza box with pizza inside, - a gallon of mustard opened, 3/4 full, with a manufacturer best if used by date of 02/10/24, - two gallons of milk, one unopened and one 3/4 full, with a manufacturer best if used by date of 10/01/24. - an unopened dented gallon can of mandarin oranges was on the front of the dry food storage shelf. During an interview with [NAME] 2 on 10/02/24 at 9:55 A.M., she indicated that the kitchen serves 34 to 36 residents. All the food items that were undated or outdated would be thrown…

    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 · D2024-08-13 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to thoroughly investigate a resident's allegation of abuse for 1 of 1 abuse allegations reviewed. (Resident B) Findings include: During an interview on 08/13/24 at 10:14 A.M., the SSD (Social Services Director) indicated Resident B made some allegations of physical abuse during a meeting on 08/08/24. The SSD followed up with the resident for 72 hours related to the allegations and the resident did not repeat the allegations or have any other concerns. She did not interview any other residents about abuse. When she brought the allegation to the Administrator, he took over the investigation. The incident was reported to the State Department of Health by the Administrator on 08/08/24 at 3:28 P.M. The brief description of the incident indicated the resident told a social worker she had been locked in her closet and locked in her room and that someone choked her at night. The resident stated she had a bruise above her eye. The resident was assessed and had no bruising above her eye or on her throat. The resident had a cupboard 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-02-09 · tag F0838 — failed to assess facility resources and resident needs — widespread
    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a complete and accurate facility assessment based on the resident population and identification of resources needed to provide the necessary care and services required for their residents for 1 of 1 assessment reviewed. Finding includes: On 02/05/24 at 11:00 A.M., the Administrator provided a facility assessment form dated 12/27/23. The form was incomplete related to the care areas and population of residents in the facility and the number of residents in each care area. The form lacked resources needed during emergencies. The form lacked training topics and competencies specific to the facility. The form lacked physical environment and building/plant needs. On 02/09/24 at 2:17 P.M., the Administrator indicated he and the Director of Nursing started working on the facility assessment in November 2023. He acknowledged the facility assessment was incomplete and didn't show an accurate picture of the facility. The current facility policy, titled Facility assessment Policy, with a revision date of 06/2022, was provided…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-09 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a homelike setting for 7 of 14 residents using the shower rooms on the 100 Hall related to loose wires hanging from the walls. Findings include: On 02/07/24 at 10:11 A.M., Shower room [ROOM NUMBER] on the 100 Hall was observed. Four black electrical wires were running from a hole in the wall near the ceiling, behind the entrance door, down to the floor with the ends of the wires bundled and wound back and forth laying on the floor. The ends of the wires were wrapped with blue paper-like tape. The bundle was approximately 12 inches by 4 inches and the full length of the bundle was laying flat against the floor. During an observation and interview on 02/08/24 at 12:12 P.M., Shower room [ROOM NUMBER] on the 100 Hall had four black electrical wires hanging from a hole in the wall near the ceiling above the entrance door. The wires were draped over a second door in the shower room that led to the toilet area and hung down the door 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-09 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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, record review, and interview, the facility failed to ensure care plans were in place for residents related to a risk for skin impairments, resident's oral health status; and a care plan/physician's order related to the adequate assessment, and ongoing monitoring for the use of a seat belt and body positioning device for 3 of 14 residents reviewed for care plans. (Residents 14, 25, and 2) Findings include: 1. On 02/07/24 at 3:25 P.M., Resident 14 was observed to have an open area on his right buttock. The Wound Nurse indicated the area was newly identified and a dressing was placed on the wound daily. The clinical record for Resident 14 was reviewed on 02/07/24 at 3:41 P.M. An Annual MDS (Minimum Data Set) assessment, dated 12/11/23, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited, coronary artery disease, hypertension, chronic obstructive pulmonary disease, arthritis, and depression. The resident was at risk for skin break down and required assistance with transfers. The resident's complete Care Plan 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-09 · 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

    2. Medication administration was observed on 02/08/24 at 8:42 A.M., with RN 5 as she prepared insulin pens for Resident 24. The RN gathered a Lispro insulin pen and a Lantus insulin pen from a plastic bag and indicated the resident was to receive 17 units of Lispro (a short-acting insulin) with meals and 40 units of Lantus (a long acting insulin). The resident's blood glucose level had been 178. The nurse applied needles to both pens, not wiping off the rubber seal with an alcohol wipe, turned the dial at the end of the pens to the appropriate dose, used hand sanitizer, entered the resident's room, cleaned the resident's abdomen with an alcohol wipe, donned gloves, verified the resident's name, administered the two insulins, holding the pens in place for a few seconds following administration, and exited the room. During an interview following the administration of the insulin, the RN indicated when preparing an insulin pen for use, she would wipe off the insulin pen tip with an alcohol wipe, apply the needle, turn the pen to the required dose, and administer the insulin. 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 · D2024-02-09 · 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

    Based on observation, interview, and record review, the facility failed to adequately monitor a dialysis access site for 1 of 2 residents that received dialysis treatments. (Resident 25) Findings include: On 02/07/24 at 10:16 A.M., Resident 25 was observed in her room in her wheelchair. A dressing was observed on her right chest. The resident indicated she received dialysis treatments through the access site in her chest. She had surgery recently to place a fistula (a surgically created vascular access used for dialysis treatments) in her left arm. The fistula was not ready to be used yet, so they still used the chest access. During an interview on 02/08/24 at 12:06 P.M., RN 3 indicated the resident had a permacath access site in her chest and a fistula in her arm. Nursing staff assessed the fistula site and documented the assessment in the resident's EHR (Electronic Health Record) every shift. If a resident had a permacath, the site should be assessed to ensure the dressing was clean, dry, and intact. You would also look for signs of infection or bleeding. She did assess 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-09 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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 record review and interview, the facility failed to transcribe orders on admission for 1 of 5 residents reviewed for pharmacy services. (Resident 16) Findings include: The clinical record for Resident 16 was reviewed on 02/07/24 at 10:11 A.M. An admission MDS (Minimum Data Set) assessment, dated 01/18/24, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, hypertension, non-Alzheimer's dementia, seizure disorder, depression, and paranoid personality disorder. A Hospital Discharge summary, dated [DATE], included, but were not limited to, the following discharge medication orders: - Zyprexa/Olanzapine (an antipsychotic medication) 5 mg (milligrams) daily, and - Baclofen/Lioresal (a muscle relaxant) 5 mg, three times daily. The January and February 2024 EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) indicated the resident had received the following medications: - Olanzapine 20 mg, daily from…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-09 · 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 observation and interview, the facility failed to store medications appropriately for 2 of 3 medications rooms (Units 2 and 3) and 2 of 3 medication carts reviewed. (Units 2 and 1) Findings include: 1. On 02/08/24 at 12:10 P.M., a medication room located behind the unlocked nurse's station on Unit 2 was observed. RN 5 opened the door to the medication room without unlocking it. The room contained medical supplies and a large gray tote that was overflowing with residents' medications. The medications varied from pills to IV (intravenous) medications and the RN indicated the medications were waiting to be returned to the pharmacy. IV antibiotic medications for Resident 26 were laying on an open shelf. The RN indicated the nurses, CNA's (Certified Nurse Aides), and QMA's (Qualified Medication Aides) had access to the medication room. The medication storage room should have been locked. During an observation on 02/08/24 at 12:20 P.M., RN 5 went down the hallway to assist a resident and was out of view of the medication room. The medication room remained unlocked. 2. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“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. 1 Medicare payment denial on record.

  • Medicare payment denial — starting 2025-10-18 for 20 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to ENVIVE HEALTHCARE — 12 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 3 of 52.2+0.8 vs chain
Health inspection 2 of 52.3-0.3 vs chain
Staffing 2 of 51.8+0.2 vs chain
Quality measures 5 of 53.8+1.2 vs chain
The other 11 homes this chain runs (chain average 2.2★, 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
NBH BANKOrganization5% OR GREATER MORTGAGE INTERESTsince 12/01/2021
BORNE-BAUMAN, CANDICEIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 12/01/2021
FLUECKIGER, RUSSELLIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 12/01/2021
LEHMAN, SCOTTIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 12/01/2021
MACKLIN, LARRYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 12/01/2021
MCINTIRE, DAVIDIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 12/01/2021
ADAMS COUNTY MEMORIAL HOSPITALOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2021
LAWRENCEBURG NURSING HOLDINGS INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2021
LT CARE ACQUISITION CORPOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2021
MUSTAKLEM, MARWANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/08/2022
SMITH, SCOTTIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2021
SPRUNGER, KYLEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2021
WHEELER, DANEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2021
WOOD, PENINAHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/23/2024
BLUE MANAGEMENT SERVICES LLCOrganizationADP OF THE SNFsince 01/01/2024
ENVIVE HEALTHCARE LLCOrganizationADP OF THE SNFsince 01/01/2021
FIRST BANK OF BERNEOrganizationADP OF THE SNFsince 12/01/2021
LAWRENCEBURG PROPERTY HOLDINGS INCOrganizationADP OF THE SNFsince 12/01/2021

CMS files one row per role, so the 27 rows in the source record cover these 18 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.

8 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.

$7.0M
Net patient revenuemost recent cost report
-5.3%
Operating marginrevenue minus expenses
$1.5M
Related-party expense20% of expenses
Who pays — share of resident-days
Medicaid 81%Medicare 5%Other / private 14%

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 $1.5M paid to related parties — landlords or management companies under common ownership — equal to about 20% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$492per resident / day
operating cost
$14,956per month
≈ monthly operating cost
$467per 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 155061. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-20, 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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