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14409 Sunrise Ct, Leo, IN 46765 · Non profit - Other · 65 certified beds · (260) 627-2191 Medicare & Medicaid certified

Call the home — (260) 627-2191 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0610) — cited Aug 2024Behavioral-health or dementia-care citation — no harm found (F0744)
Insights

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

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

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

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

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
10429 Hosler Rd · (260) 627-0807 · Call to confirm hours
Pharmacy
13821 Leo Rd · (260) 627-8616 · Call to confirm hours
Grocery
13813 Fairview Dr · (260) 627-8330 · Call to confirm hours
Park
14701 Schwartz Rd · (260) 627-6321 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 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.

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 increased24.8%11.0%15.4%worse
Long-stay residents who lose too much weight4.4%5.5%5.4%better
Long-stay residents with a catheter left in their bladder2.5%0.4%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.7%1.1%2.0%better
Long-stay residents with depressive symptoms1.5%25.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury5.6%3.9%3.3%worse
Long-stay residents whose ability to walk worsened25.3%11.9%16.1%worse
Long-stay residents on antianxiety or hypnotic medication19.0%23.5%18.9%typical
Long-stay residents given the seasonal flu vaccine80.5%95.4%95.3%worse
Long-stay residents with pressure ulcers12.2%3.6%4.7%worse
Long-stay residents with worsening bladder/bowel control27.3%23.3%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table3.3%13.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Long-stay hospitalizations per 1,000 resident days2.601.611.67worse
Long-stay outpatient ER visits per 1,000 resident days0.681.441.80better

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.

10.5%U.S. median 10.7%
Went back to hospital
0.36U.S. median 0.31
Therapy hours / resident / day
0.18hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.36 therapist hours per resident per day in 2026Q1 — more than 62% of the 13,892 homes that report any therapy hours at all.

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

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a 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 SNF10.5%CMS range 7.6–16.310.7%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified90.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or 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 SNFs0.811.02Oct 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

0.73
RN hours/ resident / day
1.44
LPN hours/ resident / day
3.44
Aide hours/ resident / day
5.60
Total nurse hours/ resident / day
0.79
RN hoursweekends
55.7%
Total nursing turnover
55.6%
RN turnover

How full it usually is: this home is certified for 65 beds and averages 36.2 residents a day — about 56% occupied, or roughly 29 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 5.60 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.73 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.44 is at or above 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 5.18 hrs/resident/day on weekends vs 5.78 on weekdays — 10% thinner on weekends. RN hours go from 0.70 to 0.79 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 56% is about the same as the national median of 45%.

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

Inspection trend

3
deficiencies at the latest standard inspection (2025-09-02)
5
at the previous standard inspection (2024-09-13)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

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

  • Potential for harm · Dcited before2025-09-02 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure physician orders were followed for 3 of 12 residents reviewed (Resident 7, Resident 18 and Resident 20).Findings include: Resident 7's record was reviewed on 8/29/25 at 12:29 PM. Diagnoses included atrial fibrillation (irregular heartbeat that leads to blood clots) and anemia. Resident 7's Comprehensive Minimum Data Set (MDS), dated [DATE], indicated their Brief Interview for Mental Status (BIMS) score was 9 (moderate cognitive impairment). A physician order, dated 7/1/25, indicated Resident 7 was to be administered warfarin sodium (warfarin) 4 milligrams (mg) every Monday, Tuesday, Wednesday, Thursday and Friday for prevention of blood clots. A physician order, dated 7/5/25, indicated Resident 7 was to be administered warfarin 5 mg every Saturday and Sunday. The physician order indicated warfarin was not to be administered on Monday 8/11/25 and Tuesday 8/12/25. A lab report, dated 8/11/25, indicated Resident 7's blood clotting time…

    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 before2025-09-02 · 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 interview and record review, the facility failed to ensure resident specific accident prevention interventions were implemented for 2 of 12 residents reviewed (Resident 7 and Resident 21).Findings include: Resident 7's record was reviewed on 8/29/25 at 12:29 PM. Diagnoses included dementia and right upper arm fracture. Resident 7's Comprehensive Minimum Data Set, (MDS), dated [DATE], indicated their Brief Interview for Mental Status (BIMS) score was 9 (moderate cognitive impairment). The MDS indicated Resident 7 had no impairment of their arms or legs. The MDS indicated Resident 7 required staff supervision or touching assistance with walking. The MDS indicated Resident 7 had experienced 2 falls. A clinical assessment log indicated Resident 7 had experienced falls on the following dates: 1/18, 1/20, 1/21, 3/28, 7/30, 7/31, 8/6, 8/9, 8/12, 8/15, 8/17, 8/20, 8/22, and 8/26/25. Resident 7's care plan, dated 2/6/25, indicated they had a behavior of not waiting for staff assistance. The target goal was to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-02 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medications were disposed when expired and labeled when opened for 3 of 6 residents reviewed. (Resident 35, Resident 24, and Resident 39) On [DATE] at 9:40 AM, Registered Nurse (RN) 5 was observed preparing medications for Resident 35. An opened vial of Resident 35's insulin was observed to have a handwritten open date of [DATE]. RN 5 indicated the inulin should have been disposed of 30 days after the open date.On [DATE] at 9:47 AM, RN 5 was observed examining open medications in the medication cart. RN 5 indicated Resident 24's eye lubricant had been opened and had not been labeled with an open date. RN 5 indicated Resident 39's inhaler had been opened and had not been labeled with an open date. RN 5 indicated all medications should be labeled with the date the medication had been opened.Resident 35's record was reviewed on [DATE] at 10:55 AM. Resident 35 had been diagnosed with diabetes.A physician order indicated Resident 35 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-30 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents were treated with dignity and respect for 1 of 4 residents reviewed (Resident B). Findings include: Resident B's record was reviewed on 6/30/25 at 11:30 AM. Diagnosis included major depressive disorder, anxiety disorder and nontraumatic intracerebral hemorrhage. A report, dated 6/18/25, was provided by the Administrator on 6/30/25 at 12:33 PM. The report indicated on 6/19/25, Resident B's family reported they had observed staff talking about Resident B on their camera while care was provided to Resident B on 6/18/25. The family reported staff had indicated Resident B did not like them. An investigation timeline, dated 6/18/25 - 6/19/25, was provided by the Director of Nursing (DON) on 6/30/25 at 11:30 AM. The timeline indicated the following: On 6/18/25, the DON and Administrator met with Certified Nurse Aide (CNA) 2 for discussion of Resident B's care concerns per the family observation on Resident B's room camera. CNA 2 indicated 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-17 · 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 interview and record review the facility failed to ensure fall interventions were followed for 1 of 3 residents reviewed (Resident B). Findings include: A facility reported incident, dated 2/15/25, was provided by the Administrator on 2/17/25 at 10:58 AM. The report indicated Resident B had a fall with resultant fracture involving the distal fibula with no displacement. Resident B's record was reviewed on 2/17/25 at 11:25 AM, diagnosis included: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and dementia. A nursing note, dated 2/15/25, indicated Resident B was found in the bathroom at 9:40 AM alone on the floor due to a self transfer. The note indicated Qualified Medication Aide (QMA) 3 assisted Resident B onto the toilet, exited the room, then found Resident B on the bathroom floor around 10 AM. A nursing note, dated 2/15/25, timed 3:11 PM, indicated Certified Nurse Aide (CNA) 4 noticed swelling and bruising at Resident B's ankle. An X-ray was ordered and indicated a fracture involved the distal fibula with no displacement. A care…

    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 · Fcited before2024-09-13 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure food items were laebled and stored to prevent contamination and hand hygiene was performed consistently. 39 of 39 residents residing in the facility were served food prepared in the kitchen. Findings include: During an observation and interview on 9/9/24 at 9:16 AM, a container of chopped lettuce was observed in an assembly area with no date on the container. The lettuce was observed to have brown and yellow edges. [NAME] 2 indicated the lettuce appeared old and should not be used. A container of grape tomatoes was observed in the assembly area with no date on the container. A package of polish sausage was wrapped in foil in the freezer with no date found on the package. Bags containing corn, peas and potatoes were also found open with the packaging twisted and tied with a twist-tie in the walk-in freezer with no open dates. [NAME] 2 indicated items should be labeled and dated when opened. A package was observed in the walk-in cooler labeled turkey 9/1-9/7. [NAME] 2 indicated the turkey was expired and…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-13 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident was provided with required transfer information for a hospital transfer for 1 of 2 residents reviewed (Resident 37). Findings include: Resident 37's record was reviewed on 9/11/24 at 2:28 PM. Diagnoses included dementia, cognitive communication deficit, gastrointestinal hemorrhage and anemia. Resident 37's Quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) was 6 (severe cognitive impairment). The MDS indicated Resident 37 was being administered anticoagulants (blood thinners). A Health Status Note, dated 5/31/24 at 12:10 AM, indicated Resident 37 had been transferred to the hospital by an ambulance due to critical laboratory results. An admission summary, dated [DATE] at 11:33 PM, indicated Resident 37 had returned from the hospital at 3:00 PM. A hopsital transfer form was unable to be located in the resident's record for the date of 5/31/24. In an interview, on 9/13/24…

    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 before2024-09-13 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure physician orders related to a high-risk medication were clarified and followed for 1 of 2 residents reviewed (Resident 37). Findings include: Resident 37's record was reviewed on 9/11/24 at 2:28 PM. Diagnoses included dementia, cognitive communication deficit, gastrointestinal hemorrhage and anemia. Resident 37's Quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident's Brief Interview for Mental Status (BIMS) was 6 (severe cognitive impairment). The MDS indicated Resident 37 was being administered Eliquis (blood thinner). An Order Note, dated 5/21/24 at 12:13 PM, indicated Resident 37 had a moderate amount of rectal bleeding. New orders were obtained from the Nurse Practitioner (NP). The new orders and labs were noted into the facility laboratory (lab) system and Resident 37's medical record. A physician order, dated 5/21/24, indicated Resident 37 was to have blood tests drawn for a complete blood count (counts the different blood…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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 hand hygiene was performed during wound care for 1 of 2 residents reviewed (Resident 12). Findings include: During wound care observation, on 9/11/24 at 10:29 AM, Licensed Practical Nurse (LPN) 5 entered Resident 12's room where a tray of supplies was prepared on the bedside table containing a pair of scissors, dressing supplies, wound cleanser, and Dakins solution. LPN 5 opened the Dakins solution and poured about 10 ml in a plastic cup. She then opened a jar of wound packing, pulled out about 1 inch of packing, cut it with the scissors, and placed the packing in the cup of solution. She poured wound cleanser in another cup and placed a piece of gauze in the cup. LPN 5 removed the dressing and packing for Resident 12's right hip wound and then picked up a prepared plastic cup containing the wound cleanser and cleaned the wound with the gauze, then patted it dry with a dry piece of gauze. No hand hygiene or glove change was observed. LPN 5 picked up the cup of Dakin's solution and had the soaked packing…

    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 · D2024-09-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    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 respiratory care was provided according to physician's orders for 1 of 2 residents reviewed (Resident 29). Findings include: During an observation and interview, on 9/9/24 at 10:41 AM, Resident 29 was observed lying in bed with an oxygen concentrator positioned near the bed with tubing and a nasal cannula lying on top of the concentrator. The nasal cannula was not contained in a bag. The Director of Nursing (DON) indicated oxygen tubing not in use should be bagged to prevent contamination. During an observation, on 9/10/24 at 10:17 AM, Resident 19's oxygen concentrator was observed positioned near the bed with tubing and a nasal cannula lying on top of the concentrator. The nasal cannula was not contained in a bag. Resident 29's record was reviewed on 9/9/24 at 1:30 PM. Diagnoses included Alzheimer's disease with early onset, dyspnea, unspecified and heart failure unspecified. Resident 29's current significant change Minimum Data…

    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 11 citations
  • Potential for harm · D2024-08-14 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct a thorough investigation of an allegation of physical abuse for 1 of 3 residents reviewed for abuse (Resident N). Findings include: An incident reported to the Indiana Department of Health, dated 7/30/24, indicated Resident N had complained of severe lower back pain while being provided care by 2 staff members. The resident alleged she had been moved forcefully by the staff and had heard a snap in her back followed by severe pain. She was hospitalized on [DATE] due to the pain. A CAT (a radiology exam) scan completed at the hospital indicated she had an acute compression fracture of her lumbar vertebrae (L3/L4), which required treatment. On 8/16/24 at 1:28 P.M., Resident N's record was reviewed. Diagnoses included paraplegia (paralysis of legs and lower body) due to a progressive neurological disease, diabetes, and weakness. A significant change MDS (Minimum Data Set) assessment, dated 5/1/24, indicated the resident had no cognitive impairment,…

    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 · Dcited before2024-08-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to develop and implement person-centered interventions to promote healing of pressure ulcers for 1 of 3 residents reviewed for pressure ulcers (Resident N). Findings include: On 8/16/24 at 1:28 P.M., Resident N's record was reviewed. Diagnoses included paraplegia (paralysis of legs and lower body) due to a progressive neurological disease, diabetes, and weakness. A significant change MDS (Minimum Data Set) assessment, dated 5/1/24, indicated the resident had no cognitive impairment, no moods, behaviors or rejection of care. She had impaired range of motion (ROM) to both her upper and lower extremities and was dependent on staff for toileting, bathing, bed mobility, transfers, and lower body dressing. She required maximal assistance with upper body dressing and personal hygiene. She had a new unstageable pressure ulcer (previous MDS assessment, dated 3/13/24, indicated the resident had no pressure ulcers). A Care Area Assessment (CAA), dated 5/14/24, indicated Resident N had an unstageable pressure ulcer to her right buttock…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-22 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to ensure there was an assessment and documentation of resident's dislodged PICC (peripherally inserted central catheter) line (thin, soft tube inserted into a vein in the arm, leg or neck for long-term intravenous antibiotics, nutrition, medications, and blood draws) and PICC line site in 1 of 1 resident reviewed (Resident C). Findings include: An Indiana report form, dated 7/17/24 at 7:01 AM, indicated during morning care Certified Nursing Aide (CNA) 2 noticed Resident C's Peripherally Inserted Central Catheter (PICC) line was out of her arm. The resident indicated she was not sure how it came out. Resident C's record was reviewed on 7/17/24 at 9:42 AM. Diagnoses included sepsis, metabolic encephalopathy, and diverticulitis of the large intestine with perforation and abscess with bleeding. Resident C's current Comprehensive Minimum Data Set (MDS), dated [DATE], indicated her Basic Interview for Mental Status (BIMS) score was 14 (cognitive…

    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 · Fcited before2023-09-08 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure kitchen sanitation was maintained. 33 of 33 residents currently residing in the facility consumed food prepared in the facility kitchen. Findings include: During an observation on 9/5/23 at 6:00 AM a container of buttermilk was observed in the walk-in cooler. The container was about half full and a thick white substance was observed on top of the liquid that was a yellowish white. The date stamped on the container was 8/15/23. A container labeled lemon pudding indicated the expiration date was 9/3/23. A container labeled cherry pie filling indicated the expiration date was 8/22/23. A container labeled marshmallow sauce indicated the expiration date was 9/1/23. A container labeled western dressing was dated 7/13/23- 7/19/23. A container labeled ranch dressing did not have a date. A container stored with the other dressing bottles containing a white liquid did not have a label or date. An open package of salami was dated 8/16/23. 5 containers of salad were dated 9/1/23. In an interview on 9/5/23 at 6:22…

    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 · E2023-09-08 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) worked 8 consecutive hours in the facility 11 days of 60 reviewed. Finding includes: On 9/6/23 at 11:24 AM staff schedules for the nursing department were reviewed from 8/1/23 to 9/1/23. The staffing schedule for 8/6/23 indicated 2 agency License Practical Nurses (LPN) worked during the 24 hours. No Registered Nurse (RN) worked on 8/6/23 for 8 consecutive hours. The staffing schedule for 8/13/23 indicated 2 agency LPNs worked during the 24 hours. No RN worked on 8/13/23 for 8 consecutive hours. The staffing schedule for 8/20/23 indicated 2 agency LPNs worked during the 24 hours. A RN worked on 8/13/23 for 1.25 hours, not for 8 consecutive hours. The staffing schedule for 8/27/23 indicated 2 agency LPNs worked during the 24 hours. No RN worked on 8/27/23 for 8 consecutive hours. A review of the facility's Payroll Based Journal Report dated 1/1/23 -3/31/23, indicated the facility failed to have an RN working 8 consecutive hours per day during the fiscal quarter on the following days: 2/4/23,…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-08 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 privacy was maintained for 1 of 6 residents reviewed (Resident 23). Findings include: During an observation on 9/5/23 at 7:54 AM an Indiana Physician's Orders for Scope of Treatment (POST) form was observed taped to the wall above the head of Resident 23's bed. The form contained Resident 23's name, date of birth , a medical record number and orders pertaining to cardiopulmonary resuscitation, medical interventions, antibiotics, and artificially administered nutrition. Resident 23's record was reviewed on 9/6/23 at 11:38 AM. Diagnoses included nontraumatic intracerebral hemorrhage in hemisphere, cortical, expressive language disorder, idiopathic normal pressure hydrocephalus. A review of Resident 23's current annual Minimum Data Set (MDS) dated [DATE] indicated his Basic Interview for Mental Status (BIMS) score was 2 (severely cognitively impaired) and unable to be interviewed. During an interview on 9/6/23 at 11:35 AM, 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-08 · tag F0622 — isolated
    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to provide the resident with a written explanation of the Notice of Transfer or Discharge and Bed Hold Policy within 24 hours of a hospital transfer for 1 of 2 residents reviewed for hospitalization. (Resident 25). Findings include: Resident 25's record was reviewed on 9/05/23 at 9:04 AM. Diagnoses included hypo-osmolality, hyponatremia, type 2 diabetes mellitus, and hypertension. A review of Resident 25's current quarterly Minimum Data Set (MDS) dated [DATE] assessment indicated her Basic Interview for Mental Status (BIMS) assessment score was 13 (cognitively intact). A review of Resident 25's census record indicated she was hospitalized [DATE] to 5/20/23. A progress note, dated 5/16/23 at 7:51 PM, indicated Resident 25 had a witnessed fall and was being transported to the hospital. A progress note dated 5/20/23 at 111:27 AM indicated Resident 25 returned to the facility. A review of Resident 25's chart lacked documentation to show a Notice of Transfer 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-08 · tag F0660 — isolated
    Plan the resident's discharge to meet the resident's goals and 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 interview and record review, the facility failed to ensure the provision of a discharge summary for 1 of 7 residents reviewed. (Resident 30). Findings include: Resident 30's record was reviewed on 9/7/23 at 10:00 AM. Diagnoses included partial left foot amputation, osteomyelitis (infection in the bone) of the left ankle and foot, diabetes, irregular heartbeat, heart failure and peripheral vascular disease. A review of Resident 30's current discharge Minimum Data Set (MDS) dated [DATE] indicated their Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). The MDS indicated the resident had a surgical wound and had been prescribed blood thinners. A review of a physician order dated 7/7/23 indicated the resident required wound care to the left foot weekly and PRN for soiling and/or dislodgement. A review of a physician order dated 6/24/23 indicated the resident had been prescribed Plavix (blood thinner). A review of a physician order dated 6/23/23 indicated the resident was to be…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-08 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the provision of scheduled showers at resident preferance for 1 of 7 residents reviewed. (Resident 10). Findings include: During an interview on 6/6/23 at 9:45 AM Resident 10 indicated they had not been provided with routine showers as scheduled. Resident 10 indicated they signed each shower sheet upon completion of each shower. Resident 10 indicated they signed each shower sheet due to past episodes of the staff lying about skipping the resident's showers and then marking they had refused showers. Resident 10's record was reviewed on 9/6/23 at 10:05 AM. Diagnoses included multiple sclerosis and generalized muscle weakness. Resident 10's current comprehensive Minimum Data Set (MDS) dated [DATE] indicated their Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). The MDS indicated the resident was totally dependent on the staff for bathing. Resident 10's current care plan indicated the resident had a problem of a self-care…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-08 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure pharmacy recommendations were addressed timely for 1 of 5 residents reviewed. (Resident 12). Findings include: Resident 12's record was reviewed on 9/26/23 at 9:29 AM. Diagnoses included generalized anxiety disorder, unspecified dementia, moderate without behavioral disturbance, psychotic mood disturbance and anxiety, and heart failure, unspecified. Resident 12's current annual, Minimum Data Set (MDS) dated [DATE] indicated her Basic Interview for Mental Status (BIMS) score was 3 (severely cognitively impaired). The MDS indicated Resident 3 received antianxiety medication daily. Resident 12's current Care plan titled Uses Psychotropic Medication indicated the Resident 12 had a problem of risk of adverse effects, with a goal date of 11/30/23. Interventions included pharmacy consultations. Pharmacy Consultation Report dated 6/19/23 provided by the Administrator on 9/7/23 at 3:20 PM indicated a new order to increase Buspar to 5 mg three times daily…

    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 · D2023-08-09 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide dementia care and services for 2 of 3 residents reviewed (Resident F and Resident H). Findings include: 1. An Indiana report, dated 7/26/23, indicated Resident F was observed with purple bruising to both forearms. She indicated CNA 3 (Certified Nurse Aide) insisted she get up for breakfast; she hadn't wanted to and began to hit the CNA and told her to leave her alone. On 8/8/23 at 10:20 A.M., Resident F was observed and interviewed in her room where she sat in her wheelchair. She immediately began to pull up her sweater sleeve on the right side and indicated she had bruises from care given by a CNA. She had a large purple bruise to the top of her right hand where her skin was extremely thin. She indicated the bruises kept happening because staff were always in a rush when giving her care. She got angry when they rush or don't listen to her when she says no, so she yelled and tried to hit them. She indicated her current bruises…

    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

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to ADAMS COUNTY MEMORIAL HOSPITAL — 8 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 52.9+1.1 vs chain
Health inspection 4 of 52.6+1.4 vs chain
Staffing 4 of 53.1+0.9 vs chain
Quality measures 2 of 53.3-1.3 vs chain
The other 7 homes this chain runs (chain average 2.9★, 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
BORNE-BAUMAN, CANDICEIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2019
FLUECKIGER, RUSSELLIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 06/01/2015
LEHMAN, SCOTTIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 07/14/2020
MACKLIN, LARRYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 06/01/2015
MCINTIRE, DAVIDIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2019
ADAMS COUNTY MEMORIAL HOSPITALOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 06/01/2015
CEDAR CREEK RETIREMENT HOME INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2015
FORVIS MAZARS LLPOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
HEALTHCARE THERAPY SERVICES INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
PROACTIVE MEDICAL REVIEW AND CONSULTANTS LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
BROGUARD, DUANEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2025
BRUNE, SCOTTIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2025
DUGGAN, AMANDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/31/2023
FISCHER, PAULIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2025
KLOPFENSTEIN, JOHNIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2025
LEPLEY, WILLIAMIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2025
SCHLATTER, LOWELLIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2025
SCHLATTER, MITCHIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2025
SCHLIE, AUSTINIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2023
SCHRENK, STEVENIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2025
SMITH, SCOTTIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2020
SPRUNGER, KYLEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2018
WHEELER, DANEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 06/01/2015
YODER, THOMASIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2025
BLUE MANAGEMENT SERVICES LLCOrganizationADP OF THE SNFsince 01/01/2024
FIRST BANK OF BERNEOrganizationADP OF THE SNFsince 01/01/2020

CMS files one row per role, so the 37 rows in the source record cover these 26 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.

7 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.

$4.6M
Net patient revenuemost recent cost report
+0.4%
Operating marginrevenue minus expenses
$13K
Related-party expense0% of expenses
Who pays — share of resident-days
Medicaid 43%Medicare 3%Other / private 54%

This home reported $13K 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

$295per resident / day
operating cost
$8,956per month
≈ monthly operating cost
$296per 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 155796. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-02, 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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