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Waters Of Martinsville, The

2055 Heritage Dr, Martinsville, IN 46151 · For profit - Corporation · 103 certified beds · (765) 342-3305 Medicare & Medicaid certified

Call the home — (765) 342-3305 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0602) — most recent Sep 20252 actual-harm citations$22,165 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Sep 2025
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (34) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $22,165 in federal fines (most recent 2025-04-16)
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (2/5)
  • nursing-staff turnover (62%) runs well above the national median (45%)

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
35 Bills Blvd · (765) 335-6173 · Call to confirm hours
Pharmacy
789 State Road 39 Byp S · (765) 342-2121 · Call to confirm hours
Grocery
1209 S Main St · (765) 349-8216 · Call to confirm hours
Park
165 Morton Ave · (317) 446-5044 · 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 4 of 5
Short-stay residentsrehab / post-hospital 1 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 1 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 rating1★
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 increased4.3%11.0%15.4%better
Long-stay residents who lose too much weight9.3%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.4%0.9%better 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 symptoms24.3%25.2%6.5%typical for the state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury4.7%3.9%3.3%worse
Long-stay residents whose ability to walk worsened7.1%11.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication27.0%23.5%18.9%worse
Long-stay residents given the seasonal flu vaccine84.9%95.4%95.3%worse
Long-stay residents with pressure ulcers8.6%3.6%4.7%worse
Long-stay residents with worsening bladder/bowel control26.6%23.3%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table31.0%13.6%17.1%worse
Short-stay residents who newly got an antipsychotic medication4.4%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine50.7%79.0%79.4%worse
Short-stay residents rehospitalized after admission36.8%22.2%22.6%worse
Short-stay residents with an outpatient ER visit23.6%10.8%12.0%worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

11.9%U.S. median 10.7%
Went back to hospital
0.30U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.08hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.30 therapist hours per resident per day in 2026Q1 — more than 47% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.9%CMS range 7.4–18.510.7%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 identified65.0%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 stay5.0%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 worsened5.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.371.02Oct 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

0.58
RN hours/ resident / day
0.91
LPN hours/ resident / day
2.00
Aide hours/ resident / day
3.49
Total nurse hours/ resident / day
0.40
RN hoursweekends
62.5%
Total nursing turnover
63.6%
RN turnover

How full it usually is: this home is certified for 103 beds and averages 51.6 residents a day — about 50% occupied, or roughly 51 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.49 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.00 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 3.15 hrs/resident/day on weekends vs 3.63 on weekdays — 13% thinner on weekends. RN hours go from 0.65 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 62% is well above 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

8
deficiencies at the latest standard inspection (2025-09-29)
7
at the previous standard inspection (2024-08-02)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

34 citations, most serious first. The 12 most serious are shown; the remaining 22 are one tap away and print in full.

  • Actual harm · G2025-04-16 · 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

    A. Based on interview and record review, the facility failed to provide supervision to prevent repeated falls for a resident assessed to be a high risk for falls for 1 of 3 residents reviewed for accidents. This deficient practice resulted in a resident sustaining fractures of the wrist and hand and hospitalization for decreased mobility in lower extremities. (Resident B) B. Based on interview and record review, the facility failed to ensure a resident with an assessed behavior of wandering and a high risk of elopement was provided treatment and services to prevent an elopement which resulted in the resident going through an unlocked door and getting outside without staff knowledge for 1 of 3 residents reviewed for elopement. (Resident C) Findings include: A1. On 4/15/25 at 11:24 a.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes, osteoporosis (a condition where bones become weak and brittle), osteoarthritis (occurs when flexible tissue at the ends of bones wears down), and history of a healed traumatic fracture. A hospital…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-08-02 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent the development and worsening of facility acquired pressure ulcers for 2 of 6 residents reviewed for pressure ulcers. This deficient practice resulted in worsening and possible infection of an unstageable pressure ulcer and the development of a Stage III pressure ulcer. (Resident 34, Resident 5) Findings include: 1. On [DATE] at 2:06 p.m., Resident 34's clinical record was reviewed. The diagnoses included, but were not limited to, dementia, overactive bladder, and diabetes mellitus. The Braden Scale for Predicting Pressure Ulcer, dated [DATE] at 7:52 a.m., indicated the resident was a mild risk for developing a pressure ulcer. The Annual Minimum Data Set (MDS) assessment, dated [DATE], indicated she had severe cognitive impairment; was always incontinent of urine; frequently incontinent of bowel movements; was at risk for skin breakdown; did not currently have any pressure ulcers; had no impairments for mobility with the left…

    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 before2026-01-30 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure food was served in a safe and sanitary manner for 2 of 2 kitchen observations. Hairnets were not worn while preparing food, the dishwashing room was dirty, and expired foods were not discarded. Findings include:1. During a tour of the kitchen on 1/29/26 from 7:40 a.m. until 8:05 a.m., the following was observed.- The Activity Director and the Social Service Director were working in the kitchen, preparing meal trays, without wearing a hair net. At that time, the Social Service Director indicated they should have put on hair nets before working in the kitchen. - Inside the walk-in refrigerator observed a plastic one-gallon jug of [NAME] Chere Old Fashion Ranch Dressing with an open date of 12/29/25, and an expiration of on 12/12/25 (The dressing was opened after the expiration date). At that time, the Dietary Manager indicated the expired ranch dressing should have been removed from the refrigerator.- A buildup of debris and food…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-30 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure a sanitary and safe environment for 2 of 2 random observations. Linens were not clean, soiled briefs were left in garbage cans, and odors were present. (room [ROOM NUMBER], room [ROOM NUMBER])1. On 1/29/26 at 8:25 a.m., inside room [ROOM NUMBER] observed a large orange/brown stain on the fitted sheet on Bed B (window bed) and one urine soiled brief in the garbage can inside the bathroom. The bathroom had a strong urine odor. The bathroom was shared between room [ROOM NUMBER] and room [ROOM NUMBER]. At that time, Resident B indicated she couldn't remember when her sheets had been changed last and when she changed her own briefs, she threw her used soiled briefs in the garbage can in the bathroom.During an interview on 1/29/26 at 8:42 a.m., Resident C indicated her room had a shared bathroom with Resident B's room. Resident C had taken herself to the bathroom because she liked doing things for herself and had placed her own soiled briefs in the…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-10-22 · 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 was prepared in a sanitary manner for 1 of 3 kitchen observations. Hair was not covered, food was not labeled or discarded by manufacturer's use by date, floors and other surfaces required cleaning, and a scoop was kept in dry storage goods. These had the potential to affect 52 of 53 residents residing in the facility. (Dietary Aide 2)Findings include:During an observation of the kitchen on 10/22/25 from 12:20 p.m. to 12:50 p.m., the following was observed.-Dietary Aide 2 was observed in and around the food preparation areas. Dietary Aide 2 was observed to lack hair coverage to hair out the back and side of hair net, hanging down back and on the shoulders approximately six to eight inches in length past the hair net. -In a two-door refrigerator on the left-hand side, one full half gallon of 100 percent lactose free two percent milk with a best by date of 10/17/25. -In the walk-in refrigerator unit, on the middle left side shelf, one partially uncovered metal tray of red gelatin looking substance…

    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 · D2025-09-29 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    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 were informed of and participated in their treatment plan for 1 of 2 residents reviewed for mood and behavior. (Resident 36)Finding includes:On 9/25/25 at 2:19 p.m., Resident 36's clinical record was reviewed. The diagnoses included, but were not limited to, anxiety disorder, depression, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and dementia.A review of the resident's physician orders indicated from 7/31/25 to 8/12/25 the resident was prescribed Risperdal (antipsychotic medication) 0.5 milligrams (mg) twice daily for bipolar episodes. On 8/13/25, an order indicated the Risperdal was increased to 1 milligram (mg) twice daily.The clinical record lacked an informed consent for the increase of the antipsychotic medication on 8/13/25.During an interview with the Director of Nursing (DON) on 9/26/25 at 11:34 a.m., she indicated there was no documentation that an informed consent was provided prior to the resident receiving the increased…

    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 · D2025-09-29 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to protect the residents right to be free from physical and verbal abuse by another resident for 1 of 2 residents reviewed for abuse. (Resident 4, Resident 18)Findings include:On 9/24/25 at 10:12 a.m., Resident 4's clinical record was reviewed. The diagnoses included, but were not limited to depression, anxiety, and post-traumatic stress disorder.An 9/16/25 annual Minimum Data Set (MDS) assessment indicated the resident was cognitively intact.During an interview on 9/29/25 at 11:16 a.m., CNA 3 indicated Resident 4 was often aggressive with staff and other residents. She was aware of Resident 4 hitting Resident 18 on the head. During an interview on 9/29/25 at 11:20 a.m., LPN 2 indicated Resident 4 had an aggressive affect and she was aware of Resident 4 hitting Resident 18 on the head. During an interview on 9/29/25 at 12:10 p.m., the Administrator (ADM) indicated Resident 4 struck Resident 18 in the face after an altercation. Resident 18 shouted at another resident to stop screaming and Resident 4 went across the hallway 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-29 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the written notification required for a transfer/discharge was provided to the resident and the resident representative for 2 of 4 residents reviewed for hospitalization and discharge. (Resident 8, Resident 66) Findings include: 1. On 9/25/25 at 10:30 a.m., Resident 8's clinical record was reviewed. The diagnoses included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and delusional disorder (a mental health condition characterized by persistent, false beliefs (delusions) that are not based on reality). A review of the resident's progress notes indicated the resident was transferred to the emergency room on 7/27/25 and returned to the long-term care facility on 7/30/25. . The clinical record lacked documentation that a written notice was provided to the resident and resident representative. During an interview with the Director of Nursing (DON) on 9/26/25 at 2:19…

    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 before2025-09-29 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 an accurate assessment for 2 of 15 residents reviewed for MDS (Minimum Data Set) assessment accuracy. Antidepressants, Level II assessments, and hospice services were coded incorrectly. (Resident 39, Resident 3)Findings include: 1. On 9/25/25 at 1:42 p.m., Resident 39's clinical record was reviewed. The diagnoses included, but were not limited to, anxiety disorder, insomnia (persistent problems falling and staying asleep), and depression. The admission Minimum Data Set (MDS) assessment, dated 9/8/25, did not indicate the resident was on an antidepressant medication and indicated the resident had not received a Preadmission Screening and Resident Review (PASRR) Level II. A review of Resident 39's medication orders indicated, the resident was taking Escitalopram (a medication used to treat depression) 20 milligrams (mg) daily. The medication was prescribed on 8/28/25 for a diagnosis of depression, and the resident had continued to take this medication. A review of the resident's documents indicated a notice of PASRR…

    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 · D2025-09-29 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a PASARR (Preadmission Screening and Resident Review) was completed when a new mental health diagnosis was added for 1 of 3 residents reviewed for PASARR. (Resident 6)Finding includes:On 9/29/25 at 11:33 a.m., Resident 6's clinical record was reviewed. The diagnoses included, but were not limited to, dementia, depression, and anxiety.The PASARR Level I, dated 2/10/25, indicated no Level II was required due to no severe mental illness. The Level 1 indicated no mental health diagnosis was known or suspected. If new changes occur or new information refuted these findings, a new screen must be submitted.Resident 6 was admitted on [DATE] with diagnoses of depression and anxiety.The clinical record lacked a new Level I screen with the diagnoses of depression and anxiety.During an interview on 9/29/25 at 11:24 a.m., the Minimum Data Set (MDS) nurse indicated a new Level I would be done when a new diagnosis or a new psychotropic medication was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-29 · 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 a resident received the necessary intervention to promote healing of a facility acquired pressure ulcer for 1 of 3 residents reviewed for pressure ulcer. (Resident 53)Finding includes:On 9/23/25 at 12:27 p.m., Resident 53 was observed to be eating lunch in the dining room. She was observed to be wearing a yellow sock on her left foot with her left foot resting on the floor. No pressure relieving devices were observed to be on her feet or beside her wheelchair. On 9/23/25 at 2:29 p.m., Resident 53 was observed to be sitting in the hallway. She was observed to be wearing a yellow sock on her left foot with her left foot resting on the floor. No pressure relieving devices were observed to be on her feet or beside her wheelchair.On 9/24/25 at 9:43 a.m., Resident 53 was observed to be sitting in her wheelchair in the dining room. She was observed to be wearing a yellow sock on her left foot with her foot resting on the floor. No pressure relieving devices were observed to be on her feet or beside her…

    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 · D2025-09-29 · 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 a resident received the appropriate care to prevent urinary tract infections for 1 of 2 residents reviewed for urinary tract infections. (Resident 9)Findings include: On 9/26/25 at 11:31 a.m., Resident 9 was observed in the activity room with his urinary catheter bag inside of a concealed bag, which was touching the ground, below his reclining wheelchair.On 9/26/25 at 2:40 p.m., Resident 9 was observed in the activity room with his urinary catheter bag inside of a concealed bag, which was touching the ground, below his reclining wheelchair.On 9/24/25 at 10:39 a.m., Resident 9's clinical record was reviewed. The diagnoses included, but were not limited to Alzheimer's disease, type 2 diabetes mellitus, benign prostatic hyperplasia with lower urinary tract symptoms, dementia, obstructive and reflexive uropathy (a condition where urine flow is blocked in the urinary tract, leading to a buildup of urine and potential damage to the kidneys). A care plan, initiated 3/17/23, indicated the resident had a supra…

    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 22 citations
  • Potential for harm · D2025-06-30 · tag F0925 — failed to control pests — isolated
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    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 effective pest control program was in place when ants were observed inside a residents dresser drawer for 1 of 1 random observations. (Resident B) Findings include: On 6/30/25 at 12:19 p.m., observed seven ants crawling on the outside of a dresser drawer. The dresser drawer had been opened approximately 3 inches. Observed five ants crawling inside the dresser drawer. At that time, Resident B indicated the ants were in her room all the time. The ants had been found in Resident B's bed in the past. The clinical record for Resident B was reviewed on 6/30/25 at 12:34 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disorder, personality disorder, and major depressive disorder. A quarterly Minimum Data Set (MDS) assessment, dated 6/18/25, indicated Resident B was cognitively intact. On 6/30/25 at 12:44 p.m., the Administrator provided a copy of an undated facility policy, titled Pest Control Policy, and indicated this was the current policy used by the facility. A review…

    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 · Dcited before2025-04-16 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the physician was notified of the x-ray results for 1 of 3 residents reviewed for accidents. (Resident B) Findings include: On 4/15/25 at 11:24 a.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes mellitus, history of healed traumatic fracture, unsteadiness on feet, abnormal gait, osteoarthritis, and osteoporosis. Resident B's progress notes indicated the following: - On 3/23/25 at 3:00 p.m., Resident B had tried to get up out of the bed to the use the bathroom. She leaned on the bedside table and fell to the floor. She had left arm pain. The NP (nurse practitioner) was notified. New orders were received for x-ray of left arm and to notify the clinician of any change in condition. - On 3/23/25 at 10:30 p.m., the physician was notified of the x-ray results. The documentation lacked how the physician was notified. During an interview on 4/16/25 at 10:58 a.m., LPN 2 indicated she worked on 3/23/25 when Resident B fell. She notified the NP of Resident B's complaint…

    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 · D2025-04-16 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the baseline care plan was implemented for 1 of 3 residents reviewed for accidents. (Resident B) Findings include: On 4/15/25 at 11:24 a.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes mellitus, history of healed traumatic fracture, unsteadiness on feet, abnormal gait, osteoarthritis, and osteoporosis. The hospital History and Physical note, dated 3/6/25 at 7:27 p.m., indicated Resident B had osteoporosis and compression fracture of the lumbar and thoracic spine. Resident B was on fall precautions. The Baseline Care Plan, dated 3/13/25, lacked documentation of resident having a history of falls or resident's signature. The Fall Risk Review indicated the following: - On 3/13/25 at 10:26 p.m., the review indicated a high risk for falls. - On 3/24/25 at 4:27 a.m., the review indicated high risk for falls. During an interview on 4/15/25 at 11:57 a.m., the Director of Nursing (DON) indicated she presented all Resident B's care plans. At that time, a review of the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-23 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to notify the resident's representative of a significant change in the resident's physical status for 1 of 3 residents reviewed for notification of changes. (Resident B) Findings include: On 1/22/25 at 1:20 p.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, atherosclerotic heart disease and dementia. A nursing progress note, dated 9/5/24 at 10:43 p.m., indicated a pressure ulcer was newly discovered on the resident's coccyx, and a telephone call was placed in an attempt to contact the resident's family representative. Contact was not made with the representative. No further attempts to contact the resident's family representative were documented regarding the discovery of the wound. A wound assessment report, dated 9/11/24, indicated the resident had an unstageable pressure ulcer on the coccyx measuring 5 cm (centimeters) long and 2 cm wide. The wound was acquired during the resident's stay at the facility and discovered on 9/5/24. During an interview on 1/23/25 at 10:30 a.m.,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-12-30 · tag F0585 — failed to handle grievances — pattern
    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 observation, interview, and record review, the facility failed to ensure resident's grievances were acted upon and promptly resolved for residents who had food concerns for 5 of 5 residents meals reviewed. (Resident B, Resident C, Resident D, Resident E, and Resident F). Findings include: On 12/27/24 at 11:56 a.m., Resident D indicated they had not been receiving desserts or any fruit. During the Resident Council Meeting, resident's had complained about not getting any desserts or any fruit. He did not receive any fruit cocktail at lunch on that day (12/27/24). At that time, Resident D's meal tray was observed not to have any fruit cocktail. On 12/27/24 at 12:00 p.m., Resident B was observed to be in the dining room. He was observed not to have any fruit cocktail. On 12/27/24 at 12:03 p.m., Resident C was observed to be in the dining room. He was observed not to have any fruit cocktail. On 12/27/24 at 12:10 p.m., Resident E was observed to be in the dining room. He was observed not to have any fruit cocktail. On 12/27/24 at 12:15 p.m., Resident F was observed to be in the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-12-30 · tag F0800 — pattern
    Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
    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 residents with orders for house shakes were administered for 9 of 9 residents who had orders for health shakes. (Resident H, Resident J, Resident K, Resident L, Resident M, Resident B, Resident N, Resident O, Resident P) Findings include: During an interview on 12/30/24 at 11:10 a.m., the Dietary Manager (DM) indicated the facility was out of house shakes. During an interview on 12/30/24 at 11:56 a.m., the DM indicated the facility ran out of house shakes sometime over the weekend. On 12/30/24 at 1:00 p.m., the Director of Nursing (DON) presented an Order Listing Report, dated 12/30/24 at 12:54 p.m. The list indicated the following: - Resident H had an order for house shakes with meals (start date 5/21/24). - Resident J had an order for house shake three times a day (start date 11/1/24). - Resident K had an order for house shake one time a day for supplement/wound healing (start date 8/20/24). - Resident L had an order for house shake one time a day for wound healing (start date 8/20/24). - Resident M had an order…

    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 · E2024-12-30 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to follow the menus for 2 of 2 meals observed. (Resident D, Resident B, Resident C, Resident E, Resident F) Findings include: During an tour of the kitchen on 12/27/24 at 10:30 a.m., the Dietary Manager indicated the lunch menu was fried chicken, mashed potatoes, baked beans, and fruit cocktail. On 12/27/24 at 11:56 a.m., Resident D indicated they had not been receiving desserts or any fruit. During the resident council meeting, resident's had complained about not getting any desserts or any fruit. Resident D indicated he did not receive any fruit cocktail at lunch. At that time, Resident D's lunch was observed. Resident D was observed not to have any fruit cocktail. On 12/27/24 at 12:00 p.m., Resident B was observed to be in the dining room. He was observed not to have any fruit cocktail. On 12/27/24 at 12:03 p.m., Resident C was observed to be in the dining room. He was observed not to have any fruit cocktail. On 12/27/24 at 12:10 p.m., Resident E was observed to be in the dining room. He was observed not 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-03 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to notify physician of a resident's change in condition for 1 of 3 residents reviewed for medication administration. The physician was not notified of resident refusal to take medication or increased behaviors. (Resident C) Findings include: On 10/3/24 at 10:34 a.m., Resident C's clinical record was reviewed. The diagnoses included, but were not limited to, schizoaffective disorder, paranoid personality disorder, bipolar, and insomnia. A review of the resident's physician's orders indicated the following: - On 7/29/24 the resident was prescribed divalproex (an anticonvulsant medication indicated for the treatment of the manic episodes associated with bipolar disorder) extended release (ER) 1500 milligrams (mg) at bedtime for bipolar disorder. The medication was discontinued on 8/18/24. - On 8/26/24 the resident was prescribed divalproex sodium ER 1500 mg at bedtime for bipolar disorder. The medication was discontinued on 9/18/24. - On 9/27/24 the resident was prescribed divalproex sodium ER 500 mg three times a day (10:00…

    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 before2024-10-03 · 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 record review and interview, the facility failed to ensure care was provided consistent with professional standards of practice for 1 of 3 residents reviewed for pressure ulcers. Treatment orders were not implemented. (Resident B) Findings include: On 10/3/24 at 11:10 a.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, Alzheimer's Disease and depression. A Wound Assessment Report, dated 9/11/24, indicated a stage 3 pressure wound on the resident's coccyx was discovered on 9/11/24 during the resident's stay at the facility. The treatment recommendations were to daily cleanse the wound with normal saline, apply collagen particles, and cover with bordered gauze. A Wound Assessment Report, dated 9/18/24, indicated the treatment recommendations were to cleanse the wound with normal saline, apply collagen particles, and cover with a transparent film dressing 3 times a week and as needed. A Wound Assessment Report, dated 9/25/24, indicated the treatment recommendations were to cleanse the wound with normal saline, apply collagen…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-02 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure a safe and sanitary environment 6 of 6 days during the survey. A biohazard room was not secured, the nursing supply room air conditioner vent cover was not free from a dark, damp, powder-like substance, a resident room electrical outlet was not in good repair, resident bathrooms were not free of an odor of urine and feces, and resident toilets were not free of a dark substance around the toilet base. (Nursing Supply Room, Biohazard Room, Resident 29, Resident 36, Resident 42, Resident 1, Resident 8, Resident 6, Resident 49, Resident 30, Resident 41, Resident 35) Findings include: 1. On 7/28/24 at 11:04 a.m. and 7/30/24 at 11:45 a.m., the vent covering on the air conditioner in the nursing supply room was observed to have a dark, moist, powder-like substance on it. During an interview on 7/30/24 at 11:45 a.m., the Administrator indicated there was a dark, damp, black powder-like substance on the air conditioning vent cover. 2. On the following dates and times, the biohazard room near the south nursing station 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-02 · 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

    Based on interview and record review, the facility failed to ensure the written notification required for a transfer and discharge was provided to the resident and the resident representative for 2 of 4 residents reviewed for hospitalization. (Resident 1, Resident 31) Findings include: 1. Residents 1's clinical record was reviewed on 8/1/24 at 3:02 p.m. Diagnosis included, but were not limited to, chronic obstructive pulmonary disease. Resident 1's progress notes indicated the resident was sent to the hospital on 4/19/24. The clinical record lacked documentation of the written Notice of Transfer and Discharge forms having been provided to the resident. 2. On 7/30/24 at 9:47 a.m., Resident 31's clinical record was reviewed. Diagnoses included but were not limited to, schizophrenia (a serious mental health condition that affects how people think, feel and behave), dysphagia (difficulty swallowing), cognitive communication deficit (trouble reasoning and making decisions while communicating), and unspecified psychosis (collection of symptoms that affect the mind, where there has been…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-02 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the notification of the bed-hold policy required for a resident who transferred to the hospital was provided in writing to the resident for 2 of 4 residents reviewed for hospitalization. (Resident 1, Resident 31) Findings include: 1. Residents 1's clinical record was reviewed on 8/1/24 at 3:02 p.m. Diagnosis included, but were not limited to chronic obstructive pulmonary disease. Resident 1's progress notes indicated the resident was sent to the hospital on 4/19/24. The clinical record lacked documentation of written notification which specified the facility's bed-hold policy having been provided to the resident. 2. On 7/30/24 at 9:47 a.m., Resident 31's clinical record was reviewed. Diagnoses included but were not limited to, schizophrenia (a serious mental health condition that affects how people think, feel and behave), dysphagia (difficulty swallowing), cognitive communication deficit (trouble reasoning and making decisions while communicating), and unspecified psychosis (collection of symptoms that affect the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-02 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 an accurate assessment, reflective of the resident's status at the time of the assessment for 2 of 21 residents reviewed for MDS (Minimum Data Set) assessment accuracy. (Resident 31, Resident 3) Findings include: 1. On 7/30/24 at 9:47 a.m., Resident 31's clinical record was reviewed. Diagnoses included, but were not limited to, schizophrenia (a serious mental health condition that affects how people think, feel and behave), dysphagia (difficulty swallowing), cognitive communication deficit (trouble reasoning and making decisions while communicating), and unspecified psychosis (collection of symptoms that affect the mind, where there has been some loss of contact with reality). The Annual MDS assessment, dated 2/8/24, section A1500, was marked NO for PASARR (Pre-admission SCREENING AND RESIDENT REVIEW ) Level II. Section A1510 (Level II Preadmission Screening and Resident Review (PASARR) Conditions) was not completed. A Notice of PASARR Level II…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-02 · 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, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 2 residents reviewed for respiratory care. (Resident 44) Findings include: On 7/29/24 at 11:00 a.m., Resident 44 was observed to have her nasal cannula oxygen tubing up on top of the bridged of her nose and it was not labeled with a date or time. On 7/29/24 at 11:30 a.m., the Resident 44's clinical record was reviewed. The diagnoses included, but were not limited to, chronic respiratory failure with hypoxia (low levels of oxygen in your body tissues), chronic obstructive pulmonary disease (COPD), cognitive communication deficit, and dementia. A 1/10/24 physician's order indicated the resident was ordered oxygen via a nasal cannula flowing at a rate of 2 liters per minute. A 1/14/24 physician's order indicated the resident's oxygen tubing was to be changed weekly on Sunday nights. A Quarterly Minimum Data Set (MDS) assessment, dated 6/7/24, indicated the resident required oxygen therapy. During an observation on 7/30/24 at…

    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 · D2024-08-02 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 were free from significant medication errors for 1 of 4 residents reviewed for hospitalization. (Resident 31). Finding includes: On 7/30/24 at 9:47 a.m., Resident 31's clinical record was reviewed. The diagnoses included, but were not limited to, schizophrenia (a serious mental health condition that affects how people think, feel and behave), dysphagia (difficulty swallowing), cognitive communication deficit (trouble reasoning and making decisions while communicating), unspecified dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), and unspecified psychosis (collection of symptoms that affect the mind, where there has been some loss of contact with reality). The Physician's Orders included, but were not limited to: - Tamsulosin (medication to treat men who have symptoms of an enlarged prostate gland) 0.4 mg (milligrams) 1 capsule by mouth one time a day. - Olanzapine (medication to treat…

    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 · E2023-07-14 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation interview, and record review, the facility failed to provide activities designed to meet a resident's need and interests for 5 of 5 residents reviewed for activities. (Resident B, Resident C, Resident D, Resident E, and Resident F) Findings include: 1. During an observation on 7/11/23 at 11:21 a.m. through 12:00 p.m., Resident B was observed to be in the dining room. The scheduled activity of Trivia (scheduled at 11:30 a.m.) was not observed. During an observation on 7/12/23 at 10:58 a.m. through 11:45 a.m., the scheduled activity of Pretty Nails (scheduled at 11:00 a.m.) was not observed. On 7/13/23 at 11:30 a.m., the scheduled activity of Trivia was not observed. On 7/13/23 at 10:40 a.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to dementia, depression, and anxiety. A care plan, initiated on 3/21/23 and current through target date 9/11/23, indicated Resident B was dependent on staff for activities, cognitive stimulation, and social interaction due to her decline in health. She had little or no activity involvement…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-07-14 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure food was stored in a sanitary manner for 3 of 3 kitchen observations. Food was stored opened underneath a leaking water line and expired food was not discarded. Findings include: 1. During a tour of the facility's walk-in freezer on, 7/12/23 at 10:15 a.m., 7/13/23 at 10:40 a.m., and 7/13/23 at 2:13 p.m., food was observed to be stored beneath the freezer condenser water line, upon which ice had formed. The food included one 30 pound box of capri mixed vegetables open to air, one box with ice formed on it containing a 14 pound bag of capri mixed vegetables, and one box containing white bread open to air. 2. During a tour of the facility's walk-in refrigerator on 7/12/23 at 10:20 a.m., 7/13/23 at 10:45 a.m., and 7/13/23 at 2:18 p.m., expired food was observed to be stored on a shelf. The food included one opened five pound container of cottage cheese with an expiration date of 7/3/23 and one opened five pound container of sour cream with an expiration date of 7/2/23. During an interview on 7/13/23 at…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-14 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to follow physician order to notify the physician of blood glucose greater than 200 mg/dL (milligrams/deciliter) for 1 of 5 residents reviewed for unnecessary medications. (Resident F) Finding includes: On 7/12/23 at 2:45 p.m., Resident F's clinical record was reviewed. The diagnoses included, but were not limited, to dementia, Alzheimer's disease, and diabetes mellitus. The July 2023 Physician's Orders indicated to monitor blood glucose two times a day and to notify physician of blood glucose less than 70 mg/dL or greater than 200 mg/dL, initiated on 5/5/23. The July 2023 Medication Administration Record indicated the following: - On 7/2/23 at 5:00 p.m., Resident F's blood glucose was 284 mg/dL. - On 7/6/23 at 5:00 p.m., Resident F's blood glucose was 212 mg/dL. - On 7/7/23 at 5:00 p.m., Resident F's blood glucose was 273 mg/dL. - On 7/8/23 at 5:00 p.m., Resident F's blood glucose was 243 mg/dL. - On 7/9/23 at 5:00 p.m., Resident F's blood glucose was 248 mg/dL. - On 7/10/23 at 5:00 p.m., Resident F's blood glucose was 206…

    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 · D2023-07-14 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a resident was free from misappropriation of medication for 1 of 1 resident reviewed for misappropriation of property. (Resident 65) Findings include: During an interview on 7/14/23 at 3:30 p.m., the Director of Nursing (DON) indicated the nurses did a shift change narcotic count at 2:00 p.m. on 6/22/23, and the count was correct. During the next shift change count at 10:00 p.m., the resident's Dilaudid (a narcotic medication used to treat pain) count was off by 2 pills. An agency nurse, LPN 4, called the DON to report the the count was off. The DON came into the facility and LPN 4 started to cry and indicated she did not know what happened to the missing pills. The DON asked her to perform a drug test and the nurse refused because she had to go get her kids. The nurse was reported to the agency and was not permitted to return. On 7/14/23 at 3:39 p.m., Resident 65's clinical record was reviewed. The diagnoses included, but were not limited to, end stage renal disease, personal history of traumatic fracture, 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-14 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure a resident received treatment and care in accordance with the plan of care for 1 of 4 residents reviewed for skin conditions. (Resident 21) Finding includes: On 7/11/23 at 2:15 p.m., Resident 21 was observed with multiple scabbed areas and bruises to her upper extremities and forehead. During that time, the resident indicated she did not know how she got the scabbed and bruised areas. She indicated her skin was very thin and she woud get skin tears and bruises very easily. A fresh skin tear was observed to the residents upper right arm and she indicated that was from the staff pulling off an adhesive bandage. On 7/12/23 at 10:02 a.m., the resident's clinical record was reviewed. The diagnoses included, but were not limited to, lack of coordination, difficulty in walking, anemia, muscle wasting and atrophy, seizures, and muscle spasms. An admission MDS (Minimum Data Set) assessment, dated 5/10/23, indicated the resident was cognitively intact. A progress note, dated 7/10/23 at 10:21 a.m., the nurse…

    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 before2023-07-14 · 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, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for 3 of 3 residents reviewed for respiratory care. Oxygen equipment was not dated. (Resident 42, Resident 16, Resident 21) Findings include: 1. On 7/11/23 at 9:40 a.m., Resident 42 was observed sitting in his room. Next to his bed was an oxygen concentrator delivery machine. The humidifier, oxygen tubing, and oxygen mask lacked labeling to indicate the date they had been changed. On 7/12/23 at 11:48 a.m., the oxygen humidifier, tubing, and mask were observed to be without labeling to indicate the date they had been changed. On 7/13/23 at 9:50 a.m., the oxygen humidifier, tubing, and mask were observed to be without labeling to indicate the date they had been changed. On 7/11/23 at 2:30 p.m., the resident's clinical record was reviewed. The diagnoses included, but were not limited to, chronic respiratory failure and hypertension. Current physician's orders indicated the resident was prescribed oxygen as needed and at night. The oxygen…

    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
  • No harm found · C2025-09-29 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the daily census report had the actual hours worked by staff for 7 of 7 days of daily posted nurse staffing reviewed. Finding includes:On 9/23/25 at 11:30 a.m., the daily census report, dated 9/23/25, indicated no actual hours worked.On 9/29/25 at 12:23 p.m., the Administrator (ADM) presented the daily census report, dated 9/23/25 through 9/29/25. The daily census report lacked documentation of actual hours worked.During an interview on 9/29/25 at 12:58 p.m., the ADM indicated the daily census report posted lacked documentation of the actual hours worked.On 9/29/25 at 1:32 p.m., the ADM provided the facility's policy, Staffing Posting Requirement, undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .It is the policy of the facility, in cooperation with Medicare/Medicaid Services (CMS), to comply with the requirement of daily posting staff in the facility .

    Nursing and Physician Services 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

$22,165 in federal fines across 1 penalty.

  • $22,165 — penalty dated 2025-04-16

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 INFINITY HEALTHCARE CONSULTING — 69 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 1 of 52.0-1.0 vs chain
Health inspection 1 of 52.1-1.1 vs chain
Staffing 1 of 51.5-0.5 vs chain
Quality measures 2 of 53.7-1.7 vs chain
The other 68 homes this chain runs (chain average 2.0★, per CMS)
1 of 5Alpha Home - A Waters CommunityIndianapolis, IN 1 of 5Belhaven Nursing & Rehab CenterChicago, IL 1 of 5Continental Nursing & Rehab CenterChicago, IL 1 of 5Heritage Place Care & Rehabilitation LLCWinchester, TN 1 of 5Hope Creek Nursing & RehabEast Moline, IL 1 of 5Landmark Of Richton Park Rehab & Nsg CtrRichton Park, IL 1 of 5Landmark at 95th Rehabilitation and Nursing CenterChicago, IL 1 of 5Landmark of Hyde Park Rehabilitation and Nursing CChicago, IL 1 of 5Landmark of Itasca Rehabilitation and Nursing CentItasca, IL 1 of 5Landmark of Lincoln Park Rehabilitation and NursinChicago, IL 1 of 5Landmark of Oak Lawn Rehabilitation and Nursing CeOak Lawn, IL 1 of 5Momence Meadows Nursing & RehabMomence, IL 1 of 5Parker Nursing & Rehab CenterStreator, IL 1 of 5The Waters Of Smyrna, LLCSmyrna, TN 1 of 5The Waters Of Springfield LLCSpringfield, TN 1 of 5Waters Of Clifty Falls, TheMadison, IN 1 of 5Waters Of Covington, TheCovington, IN 1 of 5Waters Of Dillsboro-Ross Manor, TheDillsboro, IN 1 of 5Waters Of Georgetown, TheGeorgetown, IN 1 of 5Waters Of Hobart Skilled Nursing Facility, TheHobart, IN 1 of 5Waters Of Lebanon, TheLebanon, IN 1 of 5Waters Of Memphis A Rehabilitation & Nursing CtrMemphis, TN 1 of 5Waters Of Princeton, ThePrinceton, IN 1 of 5Waters Of Rockport Skilled Nursing Facility, TheRockport, IN 1 of 5Waters Of Scottsburg, TheScottsburg, IN 1 of 5Waters Of Sullivan Nursing Facility, TheSullivan, IN 1 of 5Waters Of Syracuse Skilled Nursing Facility, TheSyracuse, IN 1 of 5Waters Of Tipton Skilled Nursing Facility, TheTipton, IN 1 of 5Waters Of Wabash Skilled Nursing Facility East TheWabash, IN 1 of 5Waters Of Wakarusa Skilled Nursing Facility, TheWakarusa, IN 1 of 5Westpark A Waters CommunityIndianapolis, IN 2 of 5Ambassador Nursing & Rehab CenterChicago, IL 2 of 5Midway Neurological / Rehab CenterBridgeview, IL 2 of 5The Waters Of Cheatham, LLCAshland City, TN 2 of 5The Waters Of GallatinGallatin, TN 2 of 5The Waters Of Johnson City, LLCJohnson City, TN 2 of 5Waters Of Batesville, TheBatesville, IN 2 of 5Waters Of Castleton Skilled Nursing Facility, TheIndianapolis, IN 2 of 5Waters Of Dunkirk Skilled Nursing Facility, TheDunkirk, IN 2 of 5Waters Of Greencastle, TheGreencastle, IN

Showing 40 of 68; 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
PUTNAM COUNTY HOSPITALOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 05/23/2014
BRAY, ARNOLDIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 09/01/2012
FRY, JANICEIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 09/01/2012
HEADLEY, MATTHEWIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 09/01/2012
LANDRY, KEITHIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 09/01/2012
LEWIS, KATRINAIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 12/21/2022
UNDERWOOD, WENDELLIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 05/20/2024
WEATHERFORD, DENNISIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 09/18/2012
WOOD, MARKIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 08/05/2024
SILLERY, DEBRAIndividualCORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 01/03/2026
COUNTY HOSPITAL MANAGER LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 05/23/2014
WILSON, ZACHARYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/26/2020

CMS files one row per role, so the 23 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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.

$8.8M
Net patient revenuemost recent cost report
+0.3%
Operating marginrevenue minus expenses
$1.3M
Related-party expense15% of expenses
Who pays — share of resident-days
Medicaid 60%Medicare 6%Other / private 35%

This home reported $1.3M 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

$368per resident / day
operating cost
$11,173per month
≈ monthly operating cost
$369per 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 155183. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-29, 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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