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Ripley Crossing

1200 Whitlatch Way, Milan, IN 47031 · Non profit - Other · 100 certified beds · (812) 654-2231 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0602) — most recent Sep 20241 immediate-jeopardy citation$14,265 in federal fines
Insights

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

In its favor
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Sep 2024
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $14,265 in federal fines (most recent 2024-08-10)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • about 20% of its spending goes to commonly-owned related companies

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
124 W Indian Trl Ste B · (812) 654-7037 · Call to confirm hours
Pharmacy
124 W Indian Trl Ste C · (812) 654-6251 · Call to confirm hours
Grocery
Jay C2.3 mi
807 N Warpath Dr · (812) 654-2405 · Call to confirm hours
Park
N Warpath Dr · Typically dawn to dusk
Place of worship
4938 N State Road 101 · (812) 654-2582

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 3 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 3 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 2 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 rating2★
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 increased26.5%11.0%15.4%worse
Long-stay residents who lose too much weight8.2%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.3%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.9%1.1%2.0%typical
Long-stay residents with depressive symptoms11.8%25.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury6.2%3.9%3.3%worse
Long-stay residents whose ability to walk worsened19.4%11.9%16.1%worse
Long-stay residents on antianxiety or hypnotic medication16.5%23.5%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%95.4%95.3%typical
Long-stay residents with pressure ulcers3.7%3.6%4.7%better
Long-stay residents with worsening bladder/bowel control25.8%23.3%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table12.4%13.6%17.1%better
Short-stay residents who newly got an antipsychotic medication1.5%1.2%1.4%typical
Short-stay residents given the seasonal flu vaccine92.6%79.0%79.4%better
Short-stay residents rehospitalized after admission23.3%22.2%22.6%typical
Short-stay residents with an outpatient ER visit14.5%10.8%12.0%worse
Long-stay hospitalizations per 1,000 resident days3.031.611.67worse
Long-stay outpatient ER visits per 1,000 resident days2.051.441.80worse

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

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

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

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

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

58.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 72 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

58.8%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
66.1%U.S. median 56.6%
Met the expected recovery
0.17U.S. median 0.31
Therapy hours / resident / day
0.06hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 66.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 59 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.17 therapist hours per resident per day in 2026Q1 — more than 16% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF58.8%CMS range 48.2–69.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 7.2–15.210.7%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 discharge66.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge64.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge72.9%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified97.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened5.6%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.7%CMS range 3.9–14.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.761.02Oct 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

0.70
RN hours/ resident / day
1.01
LPN hours/ resident / day
2.94
Aide hours/ resident / day
4.64
Total nurse hours/ resident / day
0.50
RN hoursweekends
39.3%
Total nursing turnover
27.3%
RN turnover

How full it usually is: this home is certified for 100 beds and averages 80.2 residents a day — about 80% occupied, or roughly 20 beds typically open. It usually has some room. 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 4.64 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.70 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.94 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.11 hrs/resident/day on weekends vs 4.85 on weekdays — 15% thinner on weekends. RN hours go from 0.78 to 0.50 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%.

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

Inspection trend

5
deficiencies at the latest standard inspection (2025-12-16)
3
at the previous standard inspection (2024-10-22)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

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

  • Immediate jeopardy · Jcited before2024-08-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and observation, the facility failed to ensure a shower bed was comprehensively inspected for safety or function by the Maintenance staff or by the CNA prior to its use, failed to ensure a resident was repositioned on a shower bed using two staff in accordance with the plan of care, and failed to ensure the resident was rolled toward the CNA providing care in accordance with the CNA training record for 1 of 3 residents reviewed for accidents. (Resident B) This deficient practice resulted in Resident B falling from a shower bed and sustaining a subdural hematoma with midline shift (a potentially fatal traumatic brain injury), a fracture of the left humerus (the largest bone of the upper extremity), and a facial laceration. The immediate jeopardy began on 08/05/24, when the facility failed to ensure a resident's safety during a shower when a CNA (Certified Nurse Aide) did not follow proper procedure guidelines while turning a resident in a shower bed. The facility did not assess…

    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 before2025-12-16 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow appropriate safety measures when assisting a resident in their wheelchair, resulting in the resident falling and sustaining injuries that required hospitalization for 1 of 3 residents reviewed for accidents. (Resident B)Findings include: A Health Status Note, dated 09/08/2025 at 11:17 A.M., indicated a nurse was pushing the resident in his wheelchair up to the front lobby to leave for a dialysis treatment. The resident's feet fell to the floor causing the resident to fall forward out of the wheelchair. The resident fell face first onto the floor and immediately began to bleed from the nose. The resident was assessed for injuries, and his nose was bleeding a large amount. Pressure was applied to the resident's nose, and the resident was assisted by two staff members to a sitting position back into the wheelchair. Staff applied ice and pressure to the bridge of the resident's nose. The facility Nurse Practitioner was notified, and the resident was…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-16 · 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 record review and interview, the facility failed to notify the physician of a change in a resident's condition for 1 of 20 residents reviewed for notification of change. (Resident 82)Findings include:The clinical record for Resident 82 was reviewed on 12/11/2025 at 10:04 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 10/23/2025, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, dementia, diabetes, depression, respiratory failure, and food in the respiratory tract. A Progress Note, dated 09/22/2025 at 8:30 A.M., indicated the nurse was called to the dining room by a Certified Nurse Aide (C NA) who reported the resident was choking. The Heimlich maneuver was attempted when the resident's face went pale in color. After three to five attempts, the resident began talking and color returned to her face. The resident eventually coughed up a soggy piece of waffle. The Assistant Director of Nursing (ADON) was called to the unit to help assess the resident. The resident's Power of Attorney (POA) was…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-16 · 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 identify a pressure ulcer in a timely manner for 1 of 3 residents reviewed for pressure ulcers. (Resident 1) Findings include:During an interview and observation, on 12/11/2025 at 10:25 A.M., RN 7 indicated Resident 1 had a pressure ulcer on her coccyx. The resident was sitting in their wheelchair and refused to be transferred to bed for the wound to be observed further.The clinical record for Resident 1 was reviewed on 12/12/2025 at 1:20 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 11/03/2025, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, anemia, hypertension, heart failure, pneumonia, dementia, and schizophrenia. The resident was dependent on staff for personal hygiene and transfers.The current physician's order, with a start date of 08/06/2024, indicated the resident was to have weekly skin assessments completed on every Wednesday. The weekly skin assessments, for July 1 through August 3, 2025 indicated the resident had…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-16 · 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 proper placement of urinary catheter tubing and drainage bag for 1 of 3 residents reviewed for urinary catheters . (Resident 37) Findings include:On 12/09/2025 at 11:55 A.M., Resident 37 was observed sitting in her recliner in her room. She had recently finished working with therapy in her room. The urinary catheter drainage collection bag was hanging from the side of the recliner with three inches of the bag touching the floor. On 12/09/2025 at 1:57 P.M., Resident 37 was sitting in her recliner in her room. The urinary catheter drainage bag was hanging from the side of the recliner with three inches of the bag touching the floor. During an interview on 12/15/2025 at10:14 A.M., Certified Nurse Aide (CNA) 3 indicated the urinary catheter collection bag should be hung lower than the resident's bladder and not touching the floor. The resident needed assistance transferring from the bed to the recliner. An admission Minimum Data Set (MDS) assessment, dated 11/24/2025, indicated the resident was cognitively…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-16 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to appropriately store medications for 1 of 3 medication carts reviewed. (Wing 2 Medication Cart)Findings include: On [DATE] at 2:52 P.M., the Wing 2 Medication Cart was observed with RN 3. The Medication Cart contained a 1/4 full Humalog insulin pen for Resident 10. A sticker indicated the pen was opened on [DATE] and should be discarded by [DATE]. During an interview, on [DATE] at 2:53 P.M., RN 3 indicated the resident received insulin every day before meals. RN 3 used the pen to administer insulin to the resident before breakfast and before lunch that day. The resident probably got insulin from it yesterday too. The medication was expired and should have been discarded on [DATE].The current facility policy, titled Storage of Medications, with a revision date of [DATE], was provided by the Assistant Director of Nursing on [DATE], at 2:49 P.M. The policy indicated, .facility stores all drugs and biologicals in a safe, secure, and orderly…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-10 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to follow infection control guidelines during a dressing change and touching the floor related to hand hygiene for 1 of 4 residents reviewed for infection control. (Resident B) Findings include: During an observation, on 03/10/25 at 9:26 A.M., RN (Registered Nurse) 3 preformed hand hygiene and donned a gown and gloves to begin a wound dressing change on Resident B. She began removing the dressing from Resident B's right breast. The dressing was saturated upon removal. An egg sized wound was visualized on Resident B's right breast. A piece of the gauze, fully saturated in drainage, fell onto the floor. RN 3 picked up the saturated gauze off the floor and discard it with the used dressing in a bag. RN 3 then began cleaning the resident's wound. No hand hygiene was completed or removal of gloves. After cleansing the wound RN 3 began applying the new dressing to Resident B's right breast. RN 3 proceeded to a second dressing change on Resident B's right foot. No hand hygiene was completed in-between dressings or…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-22 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to provide safe water temperatures between 100 degrees and 120 degrees Fahrenheit per the federal guidelines for 10 of 11 residents' bathroom water access observed. (Rooms 201, 301, 302, 303, 304, 307, 308, 402, 403, and 404) Findings include: During an interview and observation on 10/17/24 at 10:35 A.M., Resident 61 indicated the water was hot but she had never been burned. The resident was standing at the sink in her room combing her hair and was able to safely walk around her room unassisted. The water stream was too hot to keep a hand under the water flow without discomfort. During an interview and observation on 10/17/24 at 10:58 A.M., Resident 33 indicated she had not had any problems with the water being too hot. The resident was able to propel herself in her wheelchair unassisted and walk with her walker. The water stream was too hot to keep a hand under the water flow without discomfort. During an interview and observation on…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-22 · 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 upon record review and interview the facility failed to accurately to complete Minimum Data Set assessments for 3 of 18 residents reviewed. (Residents 5, 57, and 61) Findings include: 1. The clinical record for Resident 5 was reviewed on 10/17/24 at 3:35 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 09/18/2024, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension, diabetes, Alzheimer's disease, anxiety, and depression. Section O, Special Treatment and Programs, indicated the resident was receiving Hospice care. Section J, Health Conditions, indicated the resident did not have a terminal diagnosis. During an interview on 10/18/24 at 11:04 A.M., the Director of Nursing (DON) indicated a local Hospice company provided care to the resident. During an interview on 10/22/24 at 2:21 P.M., the MDS Coordinator indicated she received information related to Hospice care from the resident's paper chart. The resident did have a terminal diagnosis and the MDS assessment should have been marked as such.…

    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 · D2024-10-22 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, observation, and record review, the facility failed to adequately monitor a dialysis access site for 1 of 1 resident that received dialysis treatments. (Resident 42) Findings include: During an interview on 10/16/24 at 1:29 P.M., Resident 42 indicated he received dialysis treatments three days a week. He had an arteriovenous (AV) shunt (an abnormal connection between an artery and a vein used for dialysis) in his left arm. The nurses at the facility did not assess the shunt, they did put a numbing cream on his arm before he went out to dialysis. The resident's left arm was observed on 10/22/24 at 2:07 P.M. there was no swelling, drainage, or signs of infection at the shunt site. During an interview on 10/22/24 at 9:56 A.M., Licensed Practical Nurse (LPN) 2 indicated the resident went out for dialysis on Mondays, Wednesdays, and Fridays. He had a shunt in his arm for dialysis. On dialysis days the nurses were to fill out a form that went with the resident to dialysis. They would check and document the resident's vital signs, weigh him, and assess the dialysis…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-23 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and record review, the facility failed to ensure a resident was treated with respect and dignity for 1 of 5 residents reviewed for resident rights. (Resident F) Findings include: During an observation on 09/23/24 at 8:48 A.M., CNA (Certified Nurse Aide) 3 was observed standing beside Resident F's bedside and the CNA stated, I'm not dealing with people telling me to shut up . Well then someone else can deal with you then! and then exited the resident's room into the community living room. The CNA noticed she was being observed, then she turned around and walked back into Resident F's room and began asking what the resident would like to wear today. During an interview with Resident F on 09/23/24 at 12:59 P.M., she indicated that some of the staff are mean to her, but she can't remember their names. They come into her room and say what she needs to do in a nasty way. During an interview on 09/23/24 at 1:09 P.M., LPN (Licensed Practical Nurse) 4 indicated that Resident F was pretty alert and that she talked to family daily. Resident F has dementia, but it was more…

    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 · D2024-09-23 · 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 record review and interview, the facility failed to ensure misappropriation of resident's medications did not occur for 3 of 5 residents reviewed for misappropriation. (Residents B, D, and E) Findings include: 1.The clinical record for Resident B was reviewed on 09/20/24 9:48 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 8/13/24, indicated the resident was cognitively intact. The diagnosis included, but were not limited to, anxiety and depression. A current physician's order, with a start date of 12/05/22, indicated the staff were to administer Norco (a pain medication), 5-325 mg (milligrams), 1 tablet by mouth every six hours as needed for pain. A controlled drug record for Resident B, dated 07/12/24, shows documentation for the resident's Norco medication being signed out by RN (Registered Nurse) 2 on 08/25/24 at 8:00 A.M. and at 2:00 P.M. The facility as worked schedule, provided by the Administrator on 09/23/24 at 11:30 A.M., showed that RN 2 was not working on 08/25/24. The electronic medication administration record (EMAR) for Resident B on 08/25/24 showed…

    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 · Past Non-Compliance
Show the remaining 12 citations
  • Potential for harm · D2024-08-10 · tag F0908 — failed to keep essential equipment working — isolated
    Keep all essential equipment working safely.
    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 care equipment was in safe operating condition for two of two shower beds reviewed. (Wing 3 shower bed and Wing 4 shower bed) Findings include: 1. The shower bed on Wing 3 that was being used when Resident B fell out of it on 08/05/24 was observed with the Maintenance Director on 08/08/24 at 10:24 A.M. The bed frame and railings were made of PVC (polyvinyl chloride) pipes. The bed lacked any identifying markers related to the weight limit. The bed was approximately three feet high, with rails on both sides that were approximately six inches high. A metal pin was attached at each of the four corners of the bed with a stiff plastic strip. The pins went into holes in the rails and held the rails in place. The Maintenance Director indicated staff would remove both pins on one side to lower the railing. He recently installed the plastic strips that attached the pins to the bed. Originally, there were thin black rubber strips that held the pins onto the bed, but they were easy to break. He was not…

    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 · D2024-06-05 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure residents were free from verbal and emotional abuse for 2 of 3 residents reviewed for abuse. (Residents D and B) Findings include: 1. The clinical record for Resident D was reviewed on 06/04/24 at 11:15 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 04/13/24, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, Parkinson's disease, and hypertension. During an interview on 06/04/24 at 9:49 A.M., Resident D indicated she had been mistreated by CNA (Certified Nurse Aide) 5 at the facility. Her roommate (Resident B) couldn't reach her call light and Resident D had been helping her with the blankets on her bed. CNA 5 came into their room and thought Resident D was trying to transfer Resident B into bed. CNA 5 yelled at her and told her to get back to the other side of the room. The resident indicated she wasn't doing anything wrong. CNA 3 was there when it happened. The resident had heard CNA 5 had…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-05 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed ensure staff reported an allegation of abuse in a timely manner for 2 of 3 residents reviewed for abuse. (Residents D and B) Findings include: During an interview on 06/04/24 at 2:08 P.M., CNA (Certified Nurse Aide) 3 indicated she had worked with CNA 5 on the evening of 05/18/24. The CNAs entered Resident B and D's room to assist Resident B with care. Resident D was holding onto Resident B's wheelchair. CNA 5 told Resident D to go to her own side of the room. CNA 5 said it again and started getting louder. Resident D told CNA 5 to shut up. Resident B was getting teary eyed. CNA 3 was helping Resident B, and she was unsure of what Resident D was saying, it seemed like she said she wanted to go home. CNA 3 tried to keep everyone calm. CNA 5 was speaking in a louder voice than normal. CNA 3 made CNA 5 get out of the room. CNA 3 didn't report the incident to the nurse on duty. CNA 5 worked the rest of the shift that night and worked the next day with CNA 3. CNA 3 indicated she was supposed to talk to the nurse in charge about…

    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 · Ecited before2023-08-22 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store medications appropriately for 2 of 3 medication carts reviewed. (Wing 1 and Wing 3 medication carts) Findings include: 1. The medication cart on Wing 1 was observed on 08/21/23 at 3:42 P.M., with LPN 7. The top drawer of the cart contained several medication cups containing pills nested together. The LPN indicated it was medications for the 4:00 P.M. medication pass. The cups were labeled with the residents' initials only. She was unaware of the facility policy. The cups contained the following medications for the following residents as described by the LPN: - Resident 14, bupropion (antidepressant), - Resident 42, Protonix, Gabapentin (a nerve medication), - Resident 58, Xanax (antianxiety medication, a controlled substance), - Resident 13, two Metformin tablets, - Resident 6, two Tylenol, Metformin, Buspar (antianxiety medication), - Resident 22, Metformin, - Resident 49, two Tylenol, 1.5 tabs of Lasix, - Resident 39, two Demadex (a diuretic medication), two Tylenol, - Resident 3, two Tylenol, 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-22 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure appropriate oversight of a resident's medication during 1 of 11 medication administration observations. (Resident 1) Findings Include: An observation of medication administration with RN 5, on 08/16/23 at 2:41 P.M., of Wing 4 indicated the RN prepared a cup of medications for Resident 1. The cup contained one Gabapentin 100 mg (milligrams) tablet and two Tylenol 325 mg tablets. The RN walked into the resident's room at 2:49 P.M. The resident was brushing her teeth in her bathroom and the nurse asked if she just wanted her medications left at the bedside to take at her convenience and the resident indicated, Yes. The RN left the medication cup on her over the bed table and exited the room. During an interview on 08/18/23 at 2:18 P.M., the DON (Director of Nursing) indicated she was not aware of any residents on the Health Care side of the facility that self-medicated. During an interview on 08/22/23 at 11:30 A.M., RN 5 indicated there were seven residents on Wing 4 who were independently mobile. 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 before2023-08-22 · 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 record review and interview, the facility failed to notify the physician for a change in residents' condition related to the notification of weight changes for 2 of 5 residents reviewed for notification. (Residents 47 and 57) Findings include: 1. The clinical record for Resident 47 was reviewed on 08/21/23 at 3:05 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 07/29/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, chronic kidney disease, coronary artery disease, peripheral vascular disease, and hypertension. The resident received a diuretic (water pill) medication for seven of the seven days during the review period. The Care Plan, with an initiated date of 06/07/23, indicating the resident was at risk for decreased cardiac output related to chronic kidney disease stage three, peripheral vascular disease, and atherosclerotic heart disease. The interventions included, but were not limited to, .Daily weights; Notify physician if weight gain is greater than 3 pounds in 24 hours or 5 pounds in a week . 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 · D2023-08-22 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a care plan was initiated for a resident with an intravaginal device for 1 of 20 residents reviewed for care plans. (Resident 53) Findings include: During an interview on 08/16/23 at 1:41 P.M., Resident 53 indicated she took water pills and had to go to the bathroom often. The resident's clinical record was reviewed on 08/21/23 at 10:01 A.M. An admission MDS (Minimum Data Set) assessment, dated 06/12/23, indicated the resident was moderately cognitively impaired. The resident required limited staff assistance for most ADLs (Activities of Daily Living), including toileting, but required extensive staff assistance with personal hygiene. The resident was occasionally incontinent of urine, and frequently incontinent of bowel. The diagnoses included, but were not limited to, congestive heart failure, atrial fibrillation, uterovaginal prolapse, and the presence of urinogenital implants. A facility admission Assessment, dated 06/05/23, indicated the resident was incontinent of bladder. A note in the genitourinary section…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-22 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to follow manufacturer's guidelines related to insulin pen usage for 1 of 11 residents reviewed for Quality of Care. (Resident 135) Findings include: Medication administration was observed on 08/17/23 at 11:33 A.M., on Wing 5 with RN 3. The RN prepared to check the blood sugar level of Resident 135. The nurse took a basket of supplies, donned clean gloves, and checked the resident's blood sugar level. The level was 204. The nurse unlocked the medication cart, removed a bag containing a Lispro insulin pen, indicated the resident was to receive two units of insulin, used hand sanitizer, removed the pen from the bag, removed the pen cap, applied the needle to the end of the insulin pen, turned the dose knob to two units, and administered the insulin. The nurse did not clean the hub of the pen prior to applying the needle, nor did she prime the pen before use. During an interview on 08/17/23 at 11:44 A.M., RN 3 indicated she was not trained to clean the hub of the insulin pen before applying the needle. She looks 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 · Dcited before2023-08-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview, and observation, the facility failed to ensure a resident's safety during bus transport (Resident 15), follow and implement fall interventions (Resident 57) for 2 of 6 residents reviewed for accident hazards. Findings include: 1. Resident 15's clinical record was reviewed on 08/21/23 at 2:32 P.M. A Quarterly MDS (Minimum Data Set) Assessment, dated 07/15/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, stroke, hypertension, hemiplegia, and anxiety. The resident required extensive staff assistance with bed mobility and transfers. The resident's functional range of motion was impaired on one side of their upper and lower extremities. A Health Status Note, dated 08/02/23 at 6:18 P.M., indicated the FBD (Facility Bus Driver) indicated the resident was currently at the hospital. On the way to a dental appointment that afternoon a vehicle pulled out in front of her as she was driving, and she had to slam on her brakes. The resident was in a wheelchair and slid under her safety belt and was sitting on the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-22 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to acknowledge a nutrition recommendation and document meal consumption for 1 of 2 residents reviewed for nutrition. (Resident 6) Findings include: 1a. During an interview on 8/15/23 at 12:06 P.M., LPN (Licensed Practical Nurse) 7 indicated the resident lost weight and had a poor appetite. They had increased her health shakes and she had a lot of snacks in her room. The resident had a stable weight at the time of 115 pounds. She was only 5 foot tall. She had a stroke recently and thought it might have affected the part of the brain the had to do with hunger because she just wasn't hungry anymore. During an observation and interview on 08/18/23 at 12:43 P.M., Resident 6 was sitting in her recliner in her room. She indicated she was a picky eater. She ate oatmeal every morning for breakfast. The facility was accommodating if she didn't like what was being served. She believed she had lost weight because she wasn't as active as she used to be.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-22 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    3. Resident 44's clinical record was reviewed on 08/21/23 at 10:26 A.M. A Quarterly MDS assessment, dated 06/07/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, stroke, hypertension, anemia, diabetes, anxiety, and depression. A Consultant Pharmacy Communication to Nursing form, dated 05/23/23, indicated the resident's order from the recent hospital discharge was for Bupropion XL (An antidepressant). This medication was entered in the EMAR as Bupropion SR which was not the same dosage form. The response section of the form, signed by the DON and dated 05/25/23, indicated the medication had been changed to XL. The hospital discharge orders, dated 05/20/23, indicated the resident was to continue Bupropion XL (150 mg/24 hours) one oral tablet every 24 hours. The May 2023 EMAR included, but were not limited to the following orders: - A MD order, with a start date of 04/30/23, for Bupropion HCL (hydrogen chloride) ER (extended release) (XL) oral tablet, Extended Release 24 hour 150 mg. Give one tablet in the morning for…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-22 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to follow appropriate infection control guidelines during medication administration for 1 of 11 residents observed. (Resident 57) Findings include: Medication administration was observed on Wing 4 on 08/17/23 at 11:03 A.M., with LPN (Licensed Practical Nurse) 2. The nurse was preparing to check the blood sugar of Resident 57 and indicated he was to receive six units of scheduled insulin before meals. The nurse donned gloves, then dropped the packet containing an alcohol wipe to be used for the procedure on floor. The LPN picked the alcohol wipe packet up with her gloved hand and went to check the resident's blood sugar. The resident was sitting at a table in the dining area. The nurse laid her supplies on the table and was preparing to open the packet she had just picked up off the floor. When asked what she should do since she dropped the alcohol wipe packet on the floor, she said she should get another one. She doffed her gloves and threw away the alcohol wipe, used hand sanitizer, got keys out of her pocket, got a new…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction

“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

$14,265 in federal fines across 1 penalty.

  • $14,265 — penalty dated 2024-08-10

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 MAJOR HOSPITAL — 6 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 2 of 52.6-0.6 vs chain
Health inspection 2 of 52.8-0.8 vs chain
Staffing 4 of 52.8+1.2 vs chain
Quality measures 3 of 53.4-0.4 vs chain
The other 5 homes this chain runs (chain average 2.6★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleSince
COFFIN, JOHNIndividualCORPORATE DIRECTORsince 07/01/2020
SANDMAN, JANIndividualCORPORATE DIRECTORsince 07/01/2020
CLAXTON, RYANIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/27/2025
RIPLEY CROSSING HEALTH SERVICES INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2020
GOODMAN, ALLENIndividualOPERATIONAL/MANAGERIAL CONTROLsince 07/01/2020
JOHNSON, TRINAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2020
DLR INVESTMENTS, INC.OrganizationADP OF THE SNFsince 07/01/2020
GOODWEATHER, LLCOrganizationADP OF THE SNFsince 07/01/2020

CMS files one row per role, so the 12 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

3 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.

$9.0M
Net patient revenuemost recent cost report
-3.2%
Operating marginrevenue minus expenses
$1.9M
Related-party expense20% of expenses
Who pays — share of resident-days
Medicaid 64%Medicare 5%Other / private 30%

This home reported $1.9M paid to related parties — landlords or management companies under common ownership — equal to about 20% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$318per resident / day
operating cost
$9,669per month
≈ monthly operating cost
$308per 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 155730. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-16, 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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