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Cedar Creek Health Campus

18275 Burr Street, Lowell, IN 46356 · For profit - Corporation · 58 certified beds · (219) 696-6750 Medicare & Medicaid certified

Call the home — (219) 696-6750 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citations — no harm found (F0744, F0758)1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$8,021 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • lower-than-typical staff turnover (27% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,021 in federal fines (most recent 2024-05-28)
  • its facility-reported quality-measure score sits well above its independent inspection score

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 3 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 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
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
27648 Morse Dt · (219) 696-6258 · Call to confirm hours
Pharmacy
Walgreens0.8 mi
1704 E Commercial Ave · (219) 696-6638 · Call to confirm hours
Grocery
Aldi0.8 mi
1720 E Commercial Ave · (855) 955-2534 · Call to confirm hours
Park
350 Joe Martin Rd · 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 5 of 5
Long-stay residentspeople who live here 5 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 held steady at 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased11.3%11.0%15.4%better
Long-stay residents who lose too much weight0.0%5.5%5.4%check this — see note marked star below the table
Long-stay residents with a catheter left in their bladder0.7%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 symptoms4.2%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 injury3.9%3.9%3.3%worse
Long-stay residents whose ability to walk worsened0.0%11.9%16.1%check this — see note marked star below the table
Long-stay residents on antianxiety or hypnotic medication25.9%23.5%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.4%95.3%typical
Long-stay residents with pressure ulcers3.9%3.6%4.7%better
Long-stay residents with worsening bladder/bowel control19.9%23.3%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table7.9%13.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.8%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine98.3%79.0%79.4%better
Short-stay residents rehospitalized after admission21.9%22.2%22.6%typical
Short-stay residents with an outpatient ER visit11.8%10.8%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.291.611.67better
Long-stay outpatient ER visits per 1,000 resident days1.261.441.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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.

58.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 150 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

58.6%U.S. median 51.5%
Got home and stayed home
12.9%U.S. median 10.7%
Went back to hospital
85.3%U.S. median 56.6%
Met the expected recovery
0.52U.S. median 0.31
Therapy hours / resident / day
0.24hours / resident / day
Physical therapy
0.24hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 85.3% 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 129 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 0.52 therapist hours per resident per day in 2026Q1 — more than 82% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 13% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF58.6%CMS range 52.6–65.751.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.9%CMS range 9.6–16.110.7%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 discharge85.3%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 discharge79.8%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 discharge81.4%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.1%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 hospitalization6.0%CMS range 3.2–10.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.221.02Oct 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

0.90
RN hours/ resident / day
0.97
LPN hours/ resident / day
1.71
Aide hours/ resident / day
3.58
Total nurse hours/ resident / day
0.81
RN hoursweekends
27.1%
Total nursing turnover
28.6%
RN turnover

How full it usually is: this home is certified for 58 beds and averages 54.9 residents a day — about 95% occupied, or roughly 3 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.58 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.90 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.71 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 3.05 hrs/resident/day on weekends vs 3.79 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.93 to 0.81 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 27% is below 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

6
deficiencies at the latest standard inspection (2026-05-18)
8
at the previous standard inspection (2025-03-24)

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.

25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2024-06-05 · 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 record review and interview, the facility failed to ensure adequate supervision was provided to a cognitively impaired resident with a history of exit seeking and failed to ensure an alarmed door was effectively secured to prevent elopement for 1 of 6 residents reviewed for elopement risk. (Resident M) This deficient practice resulted in Resident M exiting the facility and being picked up by a stranger who activated 911. The immediate jeopardy began on 5/25/24 when a cognitively impaired male resident, with a history of exit seeking and a Wanderguard (door alarm bracelet used to monitor residents who wander) in place, exited the facility without staff knowledge and ambulated 0.3 miles away from the facility. The resident was absent from the facility for approximately 35 minutes, had just been medicated with an as needed anti-anxiety medication (Xanax), and was also at risk for falls. The Administrator, Assistant Director of Nursing (ADON), RN Clinical Support Nurse, and the Area Executive Director were…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · D2026-05-18 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) comprehensive assessment was accurately completed related to insulin for 1 of 16 MDS assessments reviewed. (Resident 15)Finding includes:Record review for Resident 15 was completed on 5/12/26 at 3:16 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus.The admission MDS assessment, dated 3/17/26, indicated the resident had received an insulin injection in the past seven days.The Medication Administration Record, dated 3/2026, lacked documentation of any insulin administration.The Physician's Order Summary, dated 5/2026, lacked any orders for insulin.During an interview on 5/13/26 at 3:05 p.m., the MDS Coordinator indicated the resident had not received any insulin and it had been marked by accident.410 IAC (Indiana Administrative Code) 16.2-3.1-31(i)

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-18 · 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 record review and interview, the facility failed to ensure care plans were implemented and in place for antibiotic medication use for 1 of 16 resident care plans reviewed. (Resident 3)Finding includes:During an interview on 5/12/26 at 11:00 a.m., Resident 3's family member indicated the resident was taking antibiotics routinely due to a history of urinary tract infections in the past.Resident 3's record was reviewed on 5/12/26 at 1:26 p.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance and urinary tract infection.The Quarterly Minimum Data Set (MDS) assessment, dated 3/4/26, indicated the resident was severely cognitively impaired, she was frequently incontinent of bowel and bladder, and received antibiotic medications.A Physician's Order, dated 1/22/26, indicated Macrobid (antibiotic medication) 100 milligrams, 1 capsule daily.A Physician's Progress Note, dated 1/22/26 at 12:02 p.m., indicated the resident was seen for a follow-up per the family's request for a lump on the resident's right knee with pain and for concerns of a urinary…

    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 before2026-05-18 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure residents received the necessary treatment and services related to skin discolorations not assessed and or monitored for 2 of 3 residents reviewed for non-pressure related skin conditions. (Residents 4 and 35)Findings include:1. On 5/11/26 at 10:19 a.m., Resident 4 was observed sitting in a wheelchair in her room. The resident had a raised blue discoloration on her right forearm and a purple discoloration on her left shin. The resident indicated she was unsure how she received the discolorations. Record review for Resident 4 was completed on 5/12/26 at 1:29 p.m. Diagnoses included, but were not limited to, atrial fibrillation, stroke, and heart failure. A Care Plan, dated 4/30/26, indicated the resident was at risk for excessive bleeding and bruising related to medications. An intervention included to notify the physician of abnormal bruising.The admission Minimum Data Set (MDS) assessment, dated 5/4/26, indicated the resident was moderately cognitively impaired. The resident had a functional…

    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 before2026-05-18 · 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

    Based on observation, record review, and interview, the facility failed to ensure residents received the necessary care and treatment related to a lack of a Physician's Order for oxygen use for 1 of 2 residents reviewed for respiratory care. (Resident 4)Finding includes:On 5/11/26 at 10:19 a.m., Resident 4 was observed sitting in a wheelchair in her room. The resident had a portable oxygen concentrator hooked to the back of her wheelchair. The oxygen was on the resident via a nasal canula at 2 liters. The resident indicated she had been on oxygen for a while. Record review for Resident 4 was completed on 5/12/26 at 1:29 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD) and respiratory failure. A Care Plan, dated 4/30/26, indicated the resident had potential for shortness of breath while lying flat related to COPD. An intervention included to administer oxygen per the Physician's Order.The admission Minimum Data Set (MDS) assessment, dated 5/4/26, indicated the resident was moderately cognitively impaired. The resident had a functional…

    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 before2026-05-18 · 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, record review and interview, the facility failed to ensure infection control practices were in place and implemented related to Enhanced Barrier Precautions (EBP) and staff not wearing a gown during a peripherally inserted central catheter (PICC) medication administration observation. (Resident 22) Finding includes:During a medication administration observation on 5/14/26 at 12:54 p.m., LPN 1 was observed preparing Resident 22's medications, which included antibiotic medication to be administered intravenously through the resident's PICC line. The resident's doorway had a sign that indicated EBP was to be used. LPN 1 entered the resident's room, used hand sanitizer, and donned gloves. He had not donned a gown. He then proceeded to administer the intravenous medication through the PICC line. During an interview on 5/14/26 at 1:07 p.m., LPN 1 indicated he had not been instructed to wear a gown when administering intravenous medication through a PICC line. He was unsure if the resident had an EBP sign posted outside his door.During an interview on 5/15/26 at 8:52…

    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 · D2026-05-18 · 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 ensure a call light was working for a dependent resident for 1 of 24 resident's call lights tested. (Resident 4)Finding includes:On 5/11/26 at 10:19 a.m., Resident 4 was observed sitting in a wheelchair in her room. The resident indicated she wanted to lie down. She had pushed the button on her call light, but no one had responded. The resident pushed the button again; there was no light that illuminated from the call system in the hallway. On 5/11/26 at 10:21 a.m., LPN 1 was notified the resident's call light was not working. She then proceeded into the resident's room and pushed the button on the call light. There was no light that illuminated from the call system in the hallway. She indicated she would inform maintenance to fix the call light and would get another staff member to help her lie down.Record review for Resident 4 was completed on 5/12/26 at 1:29 p.m. Diagnoses included, but were not limited to, stroke and hemiplegia (paralysis on one side of the body).The admission Minimum Data Set (MDS)…

    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 · D2025-06-12 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    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 residents were served a therapeutic diet as ordered the physician for 2 of 3 residents reviewed for therapeutic diets. (Residents D and E) Findings include: 1. During an observation on 6/11/25 at 9:12 a.m., Resident D's breakfast meal consisted of two fried eggs, bacon, apple juice, [NAME] toast and fruit. The meal card indicated a regular diet with fortified foods was to be served. During an observation on 6/11/25 at 11:49 a.m., Resident D's lunch meal consisted of a slice of cheese pizza and a drink. At 12:17 p.m., she received a desert of cherry crisp. Resident D's record was reviewed on 6/11/25 at 4:29 p.m. The diagnoses included, but were not limited to, vascular dementia. A Quarterly Minimum Data Set (MDS) assessment, dated 3/20/25, indicated a severely impaired cognitive status, required supervision while eating, and received a therapeutic diet. A Care Plan, revised on 6/3/25, indicated the resident was at risk 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-24 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    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 concern related to missing clothing was documented and investigated for 1 of 1 residents reviewed for grievances. (Resident 6) Finding includes: During an interview on 3/17/25 at 1:28 p.m., Resident 6 indicated she had been missing a baseball sweatshirt for a couple of months and it had never been replaced. She also indicated she had been missing a blue and white nightgown, for approximately the past two weeks, that had not been found or replaced. The resident's record was reviewed on 3/19/25 at 1:20 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, hypotension and muscle weakness. The Quarterly Minimum Data Set assessment for Resident 6, dated 3/14/25, indicated the resident was cognitively intact and needed substantial assistance for bed mobility and transfers. Resident grievances for the past six months were reviewed. There were no grievances from Resident 6 related to missing clothing. During an interview on 3/19/25 at 11:23 a.m., the Director of Nursing indicated she 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-24 · 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 record review and interview, the facility failed to ensure medications were administered and/or held per blood pressure parameters for 1 of 5 residents reviewed for unnecessary medications. (Resident 31) Finding includes: Resident 31's record was reviewed on 3/18/25 at 1:52 p.m. Diagnoses included, but were not limited to, Parkinson's disease, chronic kidney disease, and congestive heart failure. The Significant Change in Status Minimum Data Set (MDS) assessment, dated 1/20/25, indicated the resident was moderately cognitively impaired for daily decision making. The current March 2025 Physician Order Summary (POS) indicated the resident was to receive propranolol (high blood pressure treatment) 40 milligrams 1 tablet, hold if heart rate was less than 60 beats per minute and/or systolic blood pressure (top number of blood pressure reading) was less than 120 and hydrochlorothiazide (a diuretic medication) 25 milligrams 1 tablet, hold if systolic blood pressure is less than 120. The February and March 2025 Medication Administration Record (MAR) indicated the propranolol 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 · Dcited before2025-03-24 · 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, record review and interview, the facility failed to ensure safety measures were implemented related to a broken wheelchair brake and fall interventions were put into place as ordered for 2 of 4 residents reviewed for falls. (Residents 48 and 55) Findings include: 1. On 3/17/25 at 11:28 a.m., Resident 48 was observed in her room. She indicated she had fallen in the bathroom because her wheelchair was unstable and one of the locks did not work. She indicated she had reported the issue to several people. The wheelchair was present and the right brake was noted to be broken and did not work. Resident 48's record was reviewed on 3/18/25 at 11:10 a.m. Diagnoses included, but were not limited to, chronic bronchitis, heart failure, anemia and atrial fibrillation. The admission Minimum Data Set assessment, dated 2/20/25, indicated the resident was cognitively intact and required substantial assistance for bed mobility and transfers. A Nursing Progress Note, dated 3/13/25, indicated the resident was being transferred from the toilet to the locked wheelchair when she slid…

    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 14 citations
  • Potential for harm · D2025-03-24 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure an indwelling Foley (urinary) catheter collection bag was kept off of the floor and documentation of urinary output was completed for 1 of 1 resident reviewed for urinary catheters. (Resident 3) Finding includes: On 3/20/25 at 10:42 a.m. and 12:00 p.m. Resident 3 was observed in her wheelchair. The catheter collection bag was noted to be on the floor under the chair. Record review for Resident 3 was completed on 2/21/25 at 9:46 a.m. Diagnoses included, but were not limited to, neuromuscular dysfunction of bladder, urinary retention, and personal history of urinary tract infections. The Quarterly Minimum Data Set (MDS) assessment, dated 1/29/25, indicated the resident was severely cognitively impaired and had an indwelling urinary catheter. The March 2025 Physician's Order Summary, indicated an order for the resident to have an indwelling urinary catheter and to perform catheter care every shift. The current care plans, indicated the resident used a Foley (urinary) catheter for diagnosis of neurogenic…

    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 before2025-03-24 · 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

    Based on observation, record review and interview, the facility failed to ensure a resident received the necessary care and treatment related to oxygen flow rate for 1 of 1 residents reviewed for respiratory care. (Resident 16) Finding includes: On 3/18/25 at 9:37 a.m., Resident 16 was observed seated in her room. Her portable oxygen was in use and the flow meter was set on 2 liters per minute (LPM). The resident's record was reviewed on 3/18/25 at 2:10 p.m. Diagnoses included, but were not limited to, acute respiratory failure with hypoxia and metabolic encephalopathy. The Quarterly Minimum Data Set assessment, dated 1/14/25, indicated the resident was moderately cognitively impaired, used oxygen and was dependent on staff for toileting and transfer needs. A Physician's Order, dated 9/17/24 indicated the resident was to have oxygen administered at 4 lpm by nasal cannula continuously. On 3/18/25 at 11:43 a.m., the resident was observed again in her room with the oxygen flowing at 2 lpm. LPN 1 was present and indicated it should have been set on 4 lpm. She adjusted it to the correct…

    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 · D2025-03-24 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    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 pain medication was not administered prior to non-pharmacological interventions and pain monitoring completed for 1 of 5 residents reviewed for unnecessary medications. (Resident 48) Finding includes: Resident 48's record was reviewed on 3/18/25 at 11:10 a.m. Diagnoses included, but were not limited to, chronic bronchitis, heart failure, anemia and atrial fibrillation. The admission Minimum Data Set assessment, dated 2/20/25, indicated the resident was cognitively intac and required substantial assistance for bed mobility and transfers. A Physician's Order, dated 2/13/25, indicated to give acetaminophen 650 milligrams every six hours as needed for pain. The March 2025 Medication Administration Record indicated the resident received acetaminophen 15 times between 3/1-3/18/25. There was no documentation to indicate where the pain was located, what the severity of the pain was or any non-pharmacological interventions that had been attempted prior to administering the medication. A current Pain Care Plan, dated…

    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 · D2025-03-24 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure a prn (as needed) antianxiety medication was evaluated for continued use every 14 days for 1 of 5 residents reviewed for unnecessary medications. (Resident 48) Finding includes: Resident 48's record was reviewed on 3/18/25 at 11:10 a.m. Diagnoses included, but were not limited to, chronic bronchitis, heart failure, anemia and atrial fibrillation. The admission Minimum Data Set assessment, dated 2/20/25, indicated the resident was cognitively intact, required substantial assistance for bed mobility and transfers and took antianxiety medication. A Physician's Order, dated 2/13/25, indicated to give alprazolam (an antianxiety medication) 0.5 milligrams nightly prn. There was no stop date on the order. There was another Physician's Order, dated 3/17/25, to give alprazolam 0.5 milligrams nightly prn. During an interview on 3/19/25 at 11:23 a.m., the Director of Nursing indicated there had not been a 14-day stop date on the original order. 3.1-48(a)(2)

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-24 · 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, record review and interview, the facility failed to ensure infection control guidelines were in place and implemented related to Enhanced Barrier Precautions for 1 of 1 residents reviewed for isolation. (Resident 56) Finding includes: On 3/17/25 at 11:42 a.m. and 3/21/25 at 11:07 a.m., Resident 56's room was observed. There were no signs on the door or nearby indicating the resident was in Enhanced Barrier Precautions. There were no personal protective equipment (PPE) bins near the room door or inside the room. Resident 56's record was reviewed on 3/21/25 at 2:03 p.m. Diagnoses included, but were not limited to, dysphagia (difficulty swallowing) and dementia. The admission Minimum Data Set (MDS) assessment, dated 1/22/25, indicated the resident was severely cognitively impaired and required a feeding tube. A Physician's Order, dated 1/17/25, indicated the resident was on Enhanced Barrier Precautions and the staff were to wear a gown and gloves at minimum during high-contact care activities. During an interview on 3/24/25 at 1:21 p.m., the Director of Nursing…

    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 · E2025-01-21 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    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 meals were served with no more than 14 hours between an evening meal and breakfast the following day for 1 of 2 meals observed. This had the potential to affect all 11 residents that ate in the VIP Dining Room. Finding includes: During a tour of the kitchen on 1/21/25 at 8:21 a.m., the Director of Food Services (DFS) indicated breakfast was served from 7:00 a.m. to 9:00 a.m. and was open dining. There were breakfast trays being served to the Main Dining Room at the time. During an observation of the breakfast meal service on 1/21/25 at 9:27 a.m., Assistant Director of Food Services (ADFS) delivered meal trays to resident's rooms. On 1/21/25 at 10:06 a.m., 11 residents were observed seated in the VIP Dining Room and were each served breakfast meals. There were three staff members observed providing assistance to residents. During an interview on 1/21/25 at 10:58 a.m., CNA 1 indicated the residents who required assistance in the VIP Dining Room were supposed to receive their breakfast meal trays around…

    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 · D2024-09-04 · 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

    Based on record review and interview, the facility failed to ensure a resident with a diagnosis of dementia and refusals to be bathed, received bathing at least twice a week and failed to ensure the resident's plan of care and interventions reflected the behavior of bathing refusals, for 1 of 3 residents with cognitive impairment reviewed for activities of daily living (ADL) status and behaviors. (Resident E) Finding includes: During an interview on 9/3/24 at 4:35 p.m., Resident E indicated she had not had a shower/bath since admission into the facility and was unable to remember if bathing had been offered to her. Resident E's record was reviewed on 9/4/24 at 10:54 a.m. The diagnoses included, but were not limited to, dementia. A Life Enrichment Assessment, dated 7/29/24 at 11:31 a.m., indicated it was very important for her to choose the type of bathing received and showers were preferred. A Care Plan, dated 7/29/24, indicated assistance was required for ADL's. The interventions were all dated 7/29/24 and indicated the resident was not to be rushed, encouragement was to be given…

    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 before2024-05-03 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure residents received the necessary care for activities of daily living care (ADL) related to long unkempt fingernails and the lack of offering residents shaving per the plan of care for 2 of 3 residents reviewed for ADL care. (Residents 21 and 26) Findings include: 1. On 4/29/24 at 11:19 a.m., Resident 21 was observed lying in bed in her room. Her fingernails were long, thickened and discolored. The resident indicated she would like them trimmed and no one had offered to trim them. On 5/1/24 at 11:07 a.m., and again on 5/2/24 at 9:07 a.m., Resident 21 was observed in her room. Her fingernails were still long, thickened and discolored. Record review for Resident 21 was completed on 5/1/24 at 2:33 p.m. Diagnoses included, but were not limited to diabetes mellitus, dementia, stroke, and Parkinson's disease. The Quarterly Minimum Data Set (MDS) assessment, dated 2/21/24, indicated the resident was moderately cognitively impaired. The resident had an impairment on one side of the upper and lower extremities…

    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 before2024-05-03 · 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, record review, and interview, the facility failed to ensure residents received the necessary treatment and services related to the monitoring and assessment of skin discolorations for 3 of 3 residents reviewed for non-pressure related skin conditions. (Residents 38, 4, and 26) Findings include: 1. On 4/29/24 at 2:12 p.m., Resident 38 was observed sitting in her wheelchair in her room. Dark purple discolorations were noted to the tops of both hands and she had a bandaid on her right wrist. On 4/30/24 at 2:29 p.m., Resident 38 was observed sitting in her wheelchair in her room. The dark purple discolorations remained to the tops of both hands. She had bandaids on her left hand and right wrist. On 5/1/24 at 8:52 a.m., Resident 38 was observed sitting in her wheelchair in her room. The dark purple discolorations remained to the tops of both hands, and she had a bandaid on her right hand. Record review for Resident 38 was completed on 4/30/24 at 2:14 p.m. Diagnoses included, but were not limited to, atrial fibrillation, hypertension, congestive heart failure. 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 · D2024-05-03 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure a resident received the necessary treatment to prevent a decrease in range of motion related to leg rests and a foot board improperly positioned on a wheelchair for 1 of 1 residents reviewed for positioning and mobility. (Resident 154) Finding includes: On 4/30/24 at 2:41 p.m., Resident 154 was sitting in a wheelchair in the dining area of the memory care unit on the Assisted Living side of the facility. The resident was sitting with other residents who were participating in an activity. The resident was observed to have leg rests and a foot board attached to the end of her wheelchair. The leg rests and footboard were extended horizontally out aligned with the wheelchair. Underneath the resident's legs and feet was a pillow on top of the leg rests. When the resident extended her feet they would extend over the foot board so she would then pull her legs back into a bent position. The resident had attempted multiple times to move her feet off of the leg rests and place them onto the floor. An Activity…

    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 · D2024-05-03 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure a gastrostomy tube (g-tube) was properly checked for placement prior to medication administration for 1 of 16 residents observed during medication pass. (Resident 21) Finding includes: During a medication pass observation on 5/2/24 at 12:03 p.m., LPN 1 was observed preparing medications for Resident 21. She performed hand hygiene, popped two carbidopa 25 milligram (mg) tablets into a medication cup, poured the tablets into a crush bag, crushed the medication, and then put them back into the medication cup. She prepared two carbidopa-levodopa 25-100 mg tablets into a separate cup, crushed them in a bag, and then placed them back into the medication cup. She then mixed 15 milliliters (ml) of water with each medication and prepared two 30 ml and one 15 ml cup of water for flushes. Upon entrance to the resident's room, LPN 1 performed hand hygiene and donned a gown and gloves. She paused the g-tube feeding and then proceeded to check the resident's g-tube for placement with an air bolus by plunging air…

    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 · D2024-05-03 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure medications were stored appropriately related to unidentified and crushed pills found in medication cart drawers for 2 of 2 medication carts reviewed. (100 and 300 Hall carts) Findings include: 1. The 100 Hall Medication Cart was observed on 5/2/24 at 9:06 a.m. with RN 1. Upon review, there were multiple unidentified whole pills on the bottom of the drawer. The corner of the third drawer was covered with crushed up medications. During an interview at the time, RN 1 indicated the night shift staff was supposed to clean out the medication carts during their shift. During an interview on 5/2/24 at 8:58 a.m., the Director of Nursing was notified of the medications found in the medication cart and she had no further information to provide. 2. The 300 Hall Medication Cart was observed on 5/2/24 at 1:51 p.m. with RN 2. Upon review, there were two unknown whole pills on the bottom of the drawer. During an interview at the time, RN 2 indicated the night shift staff was supposed to clean out the medication carts during their…

    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 before2024-01-04 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure residents who required extensive and dependent care for activities of daily living (ADL's) received showers/bathing at least twice weekly for 3 of 3 residents reviewed for ADL's. (Residents B, C, and D) Findings include: 1. During an interview on 1/2/24 at 6:58 p.m., Resident B indicated she usually received showers, though sometimes did not get a shower and sometimes received a bed bath instead of a shower. Resident B's record was reviewed on 1/3/24 at 12:52 p.m. The diagnoses included, but were not limited to, Parkinson's disease and dementia. A Quarterly Minimum Data Set (MDS) assessment, dated 12/13/23, indicated a moderately impaired cognitive status, no behaviors, and was dependent for showers/bathing. An ADL Care Plan, dated 10/19/21, indicated assistance would be given by staff for all ADL's. The resident's shower schedule indicated showers were to be received on Wednesday and Saturday evenings. The Plan of Care for Bathing indicated in October of 2023, showers had not been completed on October 11, 14, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-04 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    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 care for and obtain Physician's Orders to care for a PICC (peripherally inserted central catheter) line and an implanted venous port (intravenous line (IV) that is inside the body with a tube attached to the port)(PAC) in accordance with professional standards of practice, related to dressing changes for 1 of 2 residents reviewed for PICC line/port care. (Residents C and F) Findings include: 1. Resident C's closed record was reviewed on 1/2/23 at 6:05 p.m. The diagnoses included, but were not limited to, stroke. A re-admission Minimum Data Set (MDS) assessment, dated 6/29/23, indicated a moderately impaired cognitive status and no IV medications ordered at the facility. A Care Plan, dated 6/26/23, indicated a PAC was present. The site care was to be completed as ordered. A Nurse's admission Progress Note, dated 6/26/23 at 2:33 p.m., indicated a PAC was present on in the right chest area and was flushed without difficulties. The dressing on the PAC was 6/22/23. There were no Physician's Orders obtained 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.

    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

$8,021 in federal fines across 1 penalty.

  • $8,021 — penalty dated 2024-05-28

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 TRILOGY HEALTH SERVICES — 123 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 54.2-0.2 vs chain
Health inspection 3 of 53.5-0.5 vs chain
Staffing 3 of 53.3-0.3 vs chain
Quality measures 5 of 54.8+0.2 vs chain
The other 122 homes this chain runs (chain average 4.2★, per CMS)
1 of 5Heritage TheFindlay, OH 1 of 5The Oaks Rehabilitation and Healthcare CenterZanesville, OH 2 of 5Homewood Health CampusLebanon, IN 2 of 5Violet Springs Health CampusPickerington, OH 2 of 5Woodmont Health CampusBoonville, IN 3 of 5Cobblestone Crossings Health CampusTerre Haute, IN 3 of 5Creasy Springs Health CampusLafayette, IN 3 of 5Cumberland Pointe Health CampusWest Lafayette, IN 3 of 5Forest Park Health CampusRichmond, IN 3 of 5Franciscan Health Care CenterLouisville, KY 3 of 5Greenleaf Health CampusElkhart, IN 3 of 5River Terrace Health CampusMadison, IN 3 of 5Scenic Hills At The MonasteryFerdinand, IN 3 of 5Smiths Mill Health CampusNew Albany, OH 3 of 5Springhurst Health CampusGreenfield, IN 3 of 5Springs Of Richmond, TheRichmond, IN 3 of 5St Mary Healthcare CenterLafayette, IN 3 of 5Stonegate Health CampusLapeer, MI 3 of 5Sun Prairie Senior LivingSun Prairie, WI 3 of 5Taylor Springs Health CampusGahanna, OH 3 of 5The Willows at Fritz FarmLexington, KY 3 of 5The Willows at HamburgLexington, KY 3 of 5The Willows at HarrodsburgHarrodsburg, KY 3 of 5The Willows at SpringhurstLouisville, KY 3 of 5Villages At Oak Ridge, TheWashington, IN 3 of 5Waunakee Valley Senior LivingWaunakee, WI 3 of 5Wellbrooke Of CarmelCarmel, IN 4 of 5Arlington Place Health CampusIndianapolis, IN 4 of 5Ashford Place Health CampusShelbyville, IN 4 of 5Aspen Place Health CampusGreensburg, IN 4 of 5Avalon Springs Health CampusValparaiso, IN 4 of 5Bethany Pointe Health CampusAnderson, IN 4 of 5Blair Ridge Health CampusPeru, IN 4 of 5Bridgepointe Health CampusVincennes, IN 4 of 5Clearvista Lake Health CampusIndianapolis, IN 4 of 5Forest Springs Health CampusLouisville, KY 4 of 5Glen Oaks Health CampusNew Castle, IN 4 of 5Glen Ridge Health CampusLouisville, KY 4 of 5Meadows Of Delphos TheDelphos, OH 4 of 5Meadows Of Ottawa TheOttawa, OH

Showing 40 of 122; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleShareSince
HANCOCK REGIONAL HOSPITALOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 12/01/2014
TRILOGY INVESTORS LLCOrganizationDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 12/01/2015
TRILOGY PRO SERVICES LLCOrganizationDIRECT OWNERSHIP INTERESTsince 12/01/2015
TRILOGY HEALTHCARE HOLDINGS INCOrganizationINDIRECT OWNERSHIP INTERESTsince 12/01/2015
BOND, MARIAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 07/01/2020
CLARK, TIMOTHYIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 05/01/2015
DAUGHERTY, JOSHUAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 01/01/2020
FELKER, DEANIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 05/01/2015
JOYNER, SARAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 01/01/2022
WILLARD, LACEYIndividualMANAGING CONTROL - GOVERNING BODYsince 07/01/2022
WILSON, ROYIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 05/01/2015
LONG, STEVENIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 06/13/2022
TRILOGY HEALTHCARE OF LOWELL LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2014
DYREK, SHELLYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/08/2023
TEODORI, KRISTINEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/15/2025
BARNEY, LEIGHIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 09/30/2025
DAVIS, DAVIDIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 09/30/2025
AMERICAN HEALTHCARE REIT HOLDINGS LPOrganizationADP OF THE SNFsince 10/01/2021
AMERICAN HEALTHCARE REIT INCOrganizationADP OF THE SNFsince 10/01/2018
GAHC3 TRILOGY JV LLCOrganizationADP OF THE SNFsince 12/01/2015
GAHC4 TRILOGY JV LLCOrganizationADP OF THE SNFsince 10/01/2018
PARAGON OUTPATIENT REHABILITATION SERVICES LLCOrganizationADP OF THE SNFsince 12/01/2015
TRILOGY MANAGEMENT SERVICES LLCOrganizationADP OF THE SNFsince 12/01/2015
TRILOGY REAL ESTATE INVESTMENT TRUSTOrganizationADP OF THE SNFsince 12/01/2015
TRILOGY REAL ESTATE LOWELL, LLCOrganizationADP OF THE SNFsince 12/01/2015
TRILOGY REIT HOLDINGS LLCOrganizationADP OF THE SNFsince 12/01/2015
TRILOGY RER LLCOrganizationADP OF THE SNFsince 07/07/2021

CMS files one row per role, so the 37 rows in the source record cover these 27 parties — each is shown once here with every role it holds. Nothing is omitted.

15 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.

$11.1M
Net patient revenuemost recent cost report
+17.5%
Operating marginrevenue minus expenses
$1.4M
Related-party expense15% of expenses
Who pays — share of resident-days
Medicaid 29%Medicare 10%Other / private 61%

This home reported $1.4M paid to related parties — landlords or management companies under common ownership — equal to about 15% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$289per resident / day
operating cost
$8,794per month
≈ monthly operating cost
$350per 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 155822. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-18, 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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