Creekside Village
1420 E Douglas Rd, Mishawaka, IN 46545 · For profit - Corporation · 100 certified beds · (574) 307-7200 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- lower-than-typical staff turnover (35% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0602), cited Oct 2023
- 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
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 3.0% | 11.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.4% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.4% | 1.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 5.6% | 25.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.8% | 3.9% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 0.0% | 11.9% | 16.1% | check this* — see note marked star below the table |
| Long-stay residents on antianxiety or hypnotic medication | 10.7% | 23.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.5% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.3% | 3.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 20.8% | 23.3% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 0.0% | 13.6% | 17.1% | check this* — see note marked star below the table |
| Short-stay residents who newly got an antipsychotic medication | 0.6% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 87.2% | 79.0% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 25.4% | 22.2% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 11.4% | 10.8% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.86 | 1.61 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.27 | 1.44 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
64.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 258 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 53.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 117 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 0.45 therapist hours per resident per day in 2026Q1 — more than 75% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 64.2%CMS range 58.6–69.1 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.1%CMS range 7.7–13.0 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 53.0% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 38.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 53.9% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 99.3% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | 98.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.4% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.4% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.9%CMS range 3.6–9.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.87 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 100 beds and averages 92.2 residents a day — about 92% occupied, or roughly 8 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.68 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.33 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.29 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 3.04 hrs/resident/day on weekends vs 3.95 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.42 to 0.12 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 35% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · D2026-03-31 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
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 staff accurately administered physician ordered medications and treatments for 2 of 2 residents reviewed for standards of care. (Residents 1 and 18)Finding includes:1. During an observation on 3/25/2025 at 2:22 P.M. Resident 1's oxygen concentrator was dirty and dusty. The filter on the back of the concentrator had a clump of dust clinging to it. A record review for Resident 1 was completed on 3/27/2026 at 8:40 A.M. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease and emphysema. Physician Orders, initiated on 3/12/2024 for Resident 1 included, but were not limited to, change oxygen tubing, change humidity, clean oxygen concentrator, and clean filter once a day on Sundays. A Medication Administration Record for Resident 1, dated March 2026, showed the oxygen tubing and humidity, and the oxygen concentrator and filter were documented as having been cleaned as indicated by staff initials on: -3/1/2026 initialed as completed by QMA 3. -3/8/2026 initialed as completed by QMA 3.…
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.
- Potential for harm · Dcited before2026-03-31 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 treatments to address a skin condition were administered for 1 of 1 reisdents reviewed for skin conditions. (Resident 18)Findings included:The clinical record of Resident 18 was reviewed on 3/30/2026 at 10:33 A.M. The resident's diagnoses included, but were no limited to: Parkinson's disease, cellulitis of right lower limb, urinary tract infection, lymphedema, neuromuscular dysfunction of bladder, muscle weakness, hypertension, pemphigus foliaceous, presence of pacemaker and personal history of other venous thrombosis and embolism. A Significant Change Minimum Data Set (MDS) assessment, dated 1/11/26, indicated Resident 18 was moderately cognitively impaired. Physician Orders included, but were not limited to: Eucerin Original (lanolin-mineral oil), dated 3/25/2026, lotion; was to be applied twice daily to dry skin and Hydrocortisone Ointment: 2.5 % strength, dated 3/25/2026, was to be applied to face, legs and lower abdomen (not the folds) for redness twice a day.A March Medication Administration…
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.
- Potential for harm · Dcited before2026-03-31 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide oxygen according to the standards of practice regarding changing oxygen tubing and cleaning the oxygen concentrator and filter for 2 of 2 residents reviewed for respiratory care. (Residents 1 and 61)Findings include: 1. During an observation on [DATE] at 2:22 P.M. Resident 1's oxygen concentrator was found to be dirty and dusty. The filter on the back of the concentrator had a clump of dust clinging to it. A record review for Resident 1 was completed on [DATE] at 8:40 A.M. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease and emphysema. Physician Orders, initiated on [DATE] for Resident 1 included, but were not limited to, oxygen at 2 liters per minute every shift, change oxygen tubing, humidity, clean oxygen concentrator, and clean filter once a day on Sundays. A Medication Administration Record for Resident 1, dated [DATE], indicated oxygen tubing was changed and the concentrator and filters were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-31 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to follow a monitor medications for 1 of 5 residents whose medications were reviewed. (Resident 3)Finding includes:Resident 3's record review was completed on 3/27/2026 at 9:15 A.M. Diagnoses included but were not limited to: dementia, major depressive disorder, morbid obesity, congestive heart failure, hypothyroidism and type 2 diabetes mellitus.Review of the physician's orders for medications for Resident 3 indicated the resident was to receive the following diabetic medications: Freestyle [NAME] insulin 5 units three times a day, Jardiance 10 mg tablet once daily and Insulin Glargine 20 units sq once a day. In addition, the resident was receiving the following medication to address thyroid issues: Levothyroxine 100 mcg once daily. A Physician's order, dated 3/20/2026, indicated Resident 3 had a blood laboratory order to have his hemoglobin A1C (measures average blood sugar levels) and thyroid-stimulating hormone (measures thyroid levels)…
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.
- Potential for harm · D2026-03-31 · tag F0790 — failed to provide dental care — isolatedProvide routine and 24-hour emergency dental care for each 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 an order for oral surgery was transcribed timely and followed timely for 1 of 19 residents who were reviewed. (Resident 3)Finding includes:During an interview on 3/25/2026 at 11:19 A.M., Resident 3 indicated he was scheduled for oral extractions for that day, but the procedure had been cancelled because the facility had not held his medication. Resident 3's record review was completed on 3/27/2026 at 9:15 A.M. Diagnoses included but were not limited to: dementia, major depressive disorder, morbid obesity, congestive heart failure and type 2 diabetes mellitus.Pre-Surgical Procedure/Surgery Instructions from a local oral surgery center dated, 3/10/2026, indicated Resident 3 was scheduled for oral surgery on 3/25/2026. The instructions indicated the facility was to hold the resident's scheduled doses of Jardiance four days prior to his surgery.A current Physician's order dated, 10/17/2024, indicated Resident 3 had been receiving 10 mg tablet of Jardiance once a day.A review of Resident 3's March 2026 Medication…
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.
- Potential for harm · Dcited before2025-03-21 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 ensure a controlled narcotic medication was either secured in a locked environment or under direct observation of the staff member administering the medication for 1 of 1 residents observed for medication administration and safety. (Resident D) Finding includes: During an observation and interview on 3/21/2025 at 10:11 A.M., Resident D had a breakfast tray and a disposable scouffle cup of medications on his bedside table by the foot of the bed. He indicated they always left his pills on his table and there was a pain pill in the cup for him. During an interview on 3/21/2025 at 10:56 A.M., LPN 2 indicated Resident D had refused his medication and he plamned to go back later to see if Resident D had taken them. He identified the medications in the cup as the following: Eliquis 2.5 mg(milligrams) (blood thinner), tamsulosin 0.4 mg (prostate), lexapro 5 mg and 10 mg (antidepressant), daily-vite (vitamin) hydrocodone-acetaminophen 5-325 mg (narcotic pain medication) and mucinex 600 mg (expectorant). He indicated he…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-13 · tag F0679 — failed to provide activities — isolatedProvide 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 ensure individual and group activities were provided per individual preferences for 1 of 1 resident reviewed for activities (Resident 11). Finding includes: During an observation, on 1/07/2025 at 11:00 A.M. Resident 11 was observed gazing off into the distance while seated in her reclining gerichair. Resident 11's chair had been placed was in the living room area of nursing pod in front of a television. The television was on, but Resident 11 was not watching the television. There was no other activity being provided that included Resident 11. During an observation on 1/08/2025 at 9:34 A.M., Resident 11 was seated in her reclining gerichair in front of the television in the living room area of the nursing pod. Resident 11 was not looking at the television during the observation nor was she involved in any type of activity program. During an observation on 1/09/2025 at 10:20 A.M., Resident 11 was observed seated in her reclining gerichair in the living room area of the nursing pod. She was noted 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.
- Potential for harm · Dcited before2025-01-13 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 assess a resident's skin or notify the Physician of the need for a treatment timely for 1 of 3 residents who were reviewed for a skin condition (Resident 30). Finding includes: During observations on the following dates, Resident 30 had multiple scratches across the top of his head in various stages of healing. Six of the scratches had thick scabs covering part of the scratches: 1/7/2024 at 11:07 A.M., 1/8/2024 at 2:06 P.M. and 1/9/2024 at 9:35 A.M. During an interview with CNA 7, completed on 1/9/2025 at 9:43 A.M., she indicated Resident 30's scratches on the top of his head were from the resident scratching himself. CNA 7 indicated Resident 30 refused nail care often and it was the family's preference that the family provided Resident 30's nail care. Resident 30's record review was completed on 1/9/2025 at 10:50 A.M. Diagnoses included, but were not limited to: chronic obstructive pulmonary disease, chronic diastolic (congestive) heart failure, cerebral palsy, schizophrenia, dysphagia, oropharyngeal phase…
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.
- Potential for harm · D2025-01-13 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide 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 interview and record review, the facility failed to obtain an admission weight and weekly weights of a newly admitted resident that resulted in an undetermined weight loss for 1 of 3 residents reviewed for a weight loss (Resident 62). Finding includes: During an interview on 1/8/2025 at 1:15 P.M., the family of Resident 62 indicated they were worried about the resident's weight because it appeared to the family the resident was losing weight. Resident 62's record review was completed on 1/9/2025 at 3:00 P.M. She was admitted on [DATE] and her diagnoses included, but were not limited to: fracture of left femur, Alzheimer's disease, dementia, anxiety, hypertension and abnormal weight loss. An admission Minimum Data Set assessment (MDS) dated , 11/27/2024, indicated Resident 62 did not have a swallowing problem, required supervision for meals and weighed 125 pounds. Resident 62's record lacked documentation that she had been weighed upon admission. A Nutrition Observation form was completed by 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.
- Potential for harm · D2025-01-13 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to follow physician's orders related to enternal feedings and water flushes for 1 of 1 resident reviewed for a gastronomy tube (G-tube) (Resident 27). Finding includes: During an observation on 1/7/2025 at 1:40 P.M., a bottle of Jevity 1.5 (enteral therapy) was disconnected from Resident 27 and hanging on an intravenous line (IV) pole. The bottle of Jevity 1.5 was dated 1/6/2024 and had 200 milliliters (mLs) left in the bottle. During an observation on 1/8/2025 at 10:40 A.M., a bottle of Jevity 1.5 was disconnected from Resident 27 and hanging on an IV pole. The bottle of Jevity 1.5 was dated 1/7/2024 and had 75 mLs remaining in the bottle. During an observation on 1/10/25 at 8:40 A.M., a bottle of Jevity 1.5 was disconnected from Resident 27 and was hanging on an IV pole with 225 mLs still remaining in the bottle. The date on the bottle was 1/9/2024. During an interview on 1/10/2025 at 8:41 A.M., LPN 5 indicated there was 225 mLs remaining in the bottle of Jevity 1.5 and it was normal for Resident 27 to have…
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.
Show the remaining 13 citations
- Potential for harm · Dcited before2025-01-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 ensure a Continuous Positive Airway Pressure (CPAP) machine and tubing was stored properly, the water provided for the machine was sealed while being stored and there was a completed order regarding settings for the machine for 1 of 2 reviewed for respiratory care. (Resident 140) Finding includes: During an observation and interview on 1/7/2025 at 10:27 A.M., Resident 140's CPAP storage bag was on the floor and the mask for the CPAP was under her bed covers. In addition, the sterile water for the machine was from a concentrator bubbler, dated 1/5/25 ,unsealed with about half the water left in the container. The resident indicated the concentrator bubbler container was what the facility used to fill her CPAP machine at night. During an observation and interview on 1/8/2025 at 9:16 A.M., Resident 140's CPAP face mask was on the bed, not stored in the bag. The sterile water container was on the nightstand empty and the resident indicated the water from the container was used last night to fill her CPAP machine.…
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.
- Potential for harm · D2025-01-13 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 a newly admitted resident received the influenza vaccine after signing the consent form for 1 out of 5 records reviewed. (Resident 141) Finding includes: During a record review on 1/10/2025 at 2:00 P.M. for Resident 141, the admission influenza vaccination consent form, dated 1/6/2025, indicated she wished to receive the influenza vaccine. The Medication Administration Record (MAR) indicated the influenza vaccine had not been administered to Resident 141. During an interview on 1/13/2025 at 10:00 A.M., the Admissions Director indicated she completed the admission paperwork, including the consents, then uploaded them into the electronic medical record. She indicated the nursing department then took care of providing the vaccinations. During an interview on 1/13/2025 at 11:19 A.M., the DON indicated the facility's process regarding vaccines was as follows: the Infection Preventionist (IP) would ask the resident if they wanted any…
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.
- Potential for harm · D2024-07-02 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 record review and interview, the facility failed to complete and submit a timely 5-day follow-up report regarding a fall investigation that had been reported to IDOH (Indiana State Department of Health) for 1 of 3 residents reviewed for falls. (Resident D) Findings include: A record review was completed, on 7/1/2024 at 11:24 A.M. The resident's diagnoses included, but were not limited to: atrial fibrillation, metabolic encephalopathy, dementia, hypertension, weakness and fracture of right pubis. A Significant Change MDS (Minimum Data Set) Assessment, dated 6/13/2024, indicated Resident D was severely cognitive impaired, required the assistance of 1 staff member for transfers and utilized a front wheeled walker for mobility. A current care plan, dated 2/15/2023, indicated the resident was at risk for falls related to: History of recent fall with fracture to right pelvic region, age, medication use, incontinence, impaired mobility. Resident's lack of understanding of her own limitations, abnormalities of gait and mobility, unsteadiness on feet and lack of coordination. A…
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.
- Potential for harm · D2024-02-09 · tag F0655 — isolatedCreate 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to create a Baseline Care Plan related to a resident whose native language was not English, and a resident with methicillin-susceptible staphylococcus aureus (MSSA), for 2 of 19 residents who were reviewed for Baseline Care Plans. (Residents 55 & 244) Findings include: 1. During an observation, on 2/5/2024 at 11:16 A.M., Resident 55 was on a video call speaking Gujarati on a personal cell phone. No picture board or language line was present in his room. During an interview, on 2/5/2024 at 11:16 A.M., Resident 55's daughter indicated her father does not speak English, and did not always understand what staff was saying, unless a family member was present to translate. A record review was completed, on 2/8/2024 at 3:31 P.M. Resident 55's diagnoses included, but were not limited to: hemiplegia and hemiparesis of dominant side, cognitive communication deficit, dysphagia, and aphasia. An admission MDS (Minimum Data Set) assessment, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-09 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 comprehensive care plans were updated related to self administration of eye drops, isolation, and NPO (nothing by mouth) status, for 3 of 22 residents whose care plans were reviewed. (Residents 20, 244, & 30) Findings include: 1. A record review was completed on 2/8/2024 at 11:32 A.M. Resident 20's diagnoses included, but were not limited to dry eye syndrome, diabetes, hypertension, and chronic pain. Resident 20's current Physician Orders included: Refresh plus eye drops 0.5% to both eyes BID (twice per day). A current Care Plan, with a revised date of 1/12/2024, indicated the resident had impaired vision and utilized glasses. An intervention, dated 5/4/2018, indicated the resident self-administered artificial tears for diagnosis of dry eyes, and kept the artificial tears at bedside. During an interview, on 2/9/2024 at 10:40 A.M., the Unit Manager indicated the resident did not self-administer eye drops. During an interview, on 2/9/2024 at 10:41…
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.
- Potential for harm · D2024-02-09 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to follow the Pharmacist's Recommendation related to the use of a diuretic medication, for 1 of 5 residents review for unnecessary medications. (Resident 8) Finding includes: A record review for Resident 8 was completed on 2/07/2024 at 10:57 A.M. Diagnoses included, but were not limited to, acute on chronic congestive heart failure. A Quarterly Minimum Data Set (MDS) assessment, dated 11/12/2023, indicated Resident 8 received a diuretic medication daily. A Physician Order, dated 5/30/2023\, indicated furosemide (diuretic) 40 milligrams (mg) orally once a day. A Pharmacy Recommendation, dated 7/27/2023, indicated Resident 8 experienced 2 falls in July 2023 and had received a medication that may cause low blood pressure. The recommendation indicated to monitor orthostatic blood pressures periodically. The Medication Administration Record (MAR) for August, September, October, and November 2023, indicated Resident 8's blood pressure was checked every other day. The MAR did not indicate the blood pressures were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-09 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a resident's psychotropic medication was not increased and deemed a failed GDR (gradual dose reduction) without adequate indication/documentation and other non-pharmacological interventions consistently implemented by facility staff, for 1 of 5 residents reviewed for unnecessary medications. (Resident 33) Finding includes: A record review was completed on, 2/7/2024 at 11:45 A.M. Resident 33's diagnoses included, but were not limited to cerebral palsy, Schizophrenia, depression, and anxiety. Resident 33's medication orders included, Seroquel (anti-psychotic) 25 mg (milligrams) every night, ordered 1/13/2023 as a GDR. A current Care Plan, with a revised date of 1/5/2024, indicated Resident 33 displays delusions/hallucinations as evidence by seeing people/things in his room and making up stories about his past. Misperceptions of staff actions or responses. He has a diagnosis of Schizophrenia with an order for anti-psychotic medication. A current Care Plan, with a revised date of 1/5/2024, indicated the resident was 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.
- Potential for harm · Dcited before2024-02-09 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 ensure medication carts were free from loose pills and failed to date opened medications in 2 of 3 medication carts observed. (Halls 100 & 200) Findings include: 1. A medication storage observation was completed, on 2/6/2024 at 10:55 A.M. with LPN 5, on the 100 Hall medication cart. The following was observed: - 10 loose pills in various drawers. - An opened and undated bottled of latanoprost eye drops. - An opened and undated bottle of potassium chloride. - An opened and undated bottle of refresh tears. During an interview, on 2/6/2024 at 11:03 A.M., LPN 5 indicted the loose pills should not be in the cart and the medications should have been dated when opened. 2. A medication storage observation was completed, on 2/6/2024 at 1:52 P.M. with LPN 3, on the 200 Hall medication cart. The following was observed: 2 loose pills in the drawer. During an interview, on 2/6/2024 at 2:00 P.M., LPN 3 indicated the loose pills should not be in the drawers. On 2/9/2024 at 11:17 A.M., the Administrator provided the policy…
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.
- Potential for harm · D2024-02-09 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, record review, and interview, the facility failed to ensure proper infection control practices were completed during 1 of 1 blood sugar checks observed. (LPN 2) Finding includes: On 2/7/2024 at 10:58 A.M., LPN 2 completed a blood sugar check of Resident 43. LPN 2 placed the accucheck device on the bedside table. He cleansed his hands with alcohol gel and applied gloves. LPN 2 then cleansed Resident 43's finger with an alcohol pad, and with an opened hand, fanned the area that was just cleansed. During an interview, on 2/7/2024 at 11:07 A.M., LPN 2 indicated he should not have fanned the area. On 2/9/2024 at 11:17 A.M., the Administrator provided the policy titled,Blood Glucose Meter Testing, dated 7/2011 and revised 1/2024, and indicated the policy was the one currently used by the facility. The policy indicated .8. Cleanse resident's fingertip with alcohol wipe and allow to air dry 3.1-18(a)
- Potential for harm · D2023-10-06 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect 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 prevent the misappropriation of a resident's narcotic pain medication for 1 of 3 residents reviewed for liquid narcotic medication (Resident B). Findings include: On 10/5/23 at 11:41 A.M., a review of the clinical record for Resident B was conducted. The resident's diagnoses included, but were not limited to: non-traumatic intracerebral hemorrhage affecting the left non-dominant side, heart disease and chronic kidney disease The resident had a Physician Order, dated 9/15/23 through 9/30/23, for liquid hydromorphone 1 mg (milligram)/ml (milliliter). The order indicated the resident was to be administered, 3 mg of the hydromorphone every 4 hours (3 ml). A Controlled Substance Record for Resident B, dated 9/25/23, indicated 90 milliliters (ml) was received by the facility. On 9/30/23 at 2:00 P.M., 4:00 P.M., 6:00 P.M., 8:00 P.M. and 10:00 P.M., 3 milliliters of liquid hydromorphone were signed out, to be administered, by LPN 2, when the order stated every 4 hours. The Medication Administration Record for September indicated…
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.
- Potential for harm · D2023-10-06 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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
Based on interview and record review, the facility failed to prevent the improper disposal of liquid narcotics for 1 of 3 residents reviewed, who were being administered liquid narcotics. (Resident B) Finding includes: On 10/5/23 at 11:41 A.M., a review of the clinical record for Resident B was conducted. The resident's diagnoses included, but were not limited to: non-traumatic intracerebral hemorrhage affecting the left non-dominant side, heart disease and chronic kidney disease The resident had a Physician Order, dated 9/15/23 through 9/30/23, for liquid hydromorphone 1 mg (milligram)/ml (milliliter). The order indicated the resident was to be administered, 3 mg of the hydromorphone every 4 hours (3 ml). LPN 2's written statement, dated 10/4/23, indicated .While getting liquid hydromorphone out of bottle on 9-30-23 I accidentally tapped bottle causing it to spill onto the cart. I wiped the cart with a tissue where medication was spilled. There was no liquid left. I either put the bottle in either the sharps container or trash can on nurse's cart. I don't recall. The blue sheet 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.
- Potential for harm · D2023-08-18 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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 a resident's responsible party of a transfer to a local emergency room following an unwitnessed fall for 1 of 3 residents reviewed for accidents. (Resident B). Findings include: On 8/16/23 at 1:14 P.M., Resident B's clinical records were reviewed and indicated the resident was admitted to the facility with diagnoses that included Barrett's esophagus, osteoarthritis, fracture of second lumbar vertebra, encephalopathy, dysphagia, gastrostomy, severe protein-calorie malnutrition, chronic respiratory failure, and weakness. An admission Minimum Data Set (MDS) assessment, dated 7/04/23, and indicated the resident required extensive assistance for activities of daily living including transfers, locomotion, dressing, eating, and toilet use. The resident required a wheelchair for mobility. An Event Report, dated 6/29/23 at 1:20 A.M., indicated Resident B had an unwitnessed fall after sitting in a recliner and first observed sitting on the ground on his bottom. The Event Report indicated the resident was sent to the emergency…
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.
- Potential for harm · D2023-08-18 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident received discharge instructions for medication administration and gastrostomy feedings for 1 of 3 residents reviewed for discharges, (Resident B). Findings includes: On 8/16/23 at 1:14 P.M., Resident B's clinical records were reviewed and indicated the resident was admitted to the facility with diagnoses that included Barrett's esophagus, osteoarthritis, fracture of second lumbar vertebra, encephalopathy, dysphagia, gastrostomy, severe protein-calorie malnutrition, and chronic respiratory failure. An admission assessment Minimum Data Set (MDS), dated [DATE], and indicated the resident required extensive assistance for activities of daily living including G-tube feeding. Review of the Physician Order Report, dated 6/28/23, indicated the resident had Gastrostomy Tube (G-tube). Orders included; instructions to cleanse G-tube site with soap and water, pat dry and apply gauze every shift; flush the G-tube with 30 mL of water before 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.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to AMERICAN SENIOR COMMUNITIES — 90 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.9 | +0.1 vs chain |
| Health inspection | 3 of 5 | 3.4 | -0.4 vs chain |
| Staffing | 2 of 5 | 2.3 | -0.3 vs chain |
| Quality measures | 5 of 5 | 4.7 | +0.3 vs chain |
The other 89 homes this chain runs (chain average 3.9★, per CMS)
Showing 40 of 89; 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 / manager | Type | Role | Since |
|---|---|---|---|
| CHIES, STEVEN | Individual | MANAGING CONTROL - GOVERNING BODY | since 03/17/2016 |
| JACKSON, BLAKE | Individual | MANAGING CONTROL - GOVERNING BODY | since 04/01/2015 |
| JACKSON, ETHAN | Individual | MANAGING CONTROL - GOVERNING BODY | since 04/01/2015 |
| JACKSON, MARK | Individual | MANAGING CONTROL - GOVERNING BODY | since 04/01/2015 |
| JACKSON, MICHAEL | Individual | MANAGING CONTROL - GOVERNING BODY | since 05/14/2024 |
| JACKSON, WESSLEY | Individual | MANAGING CONTROL - GOVERNING BODY | since 04/01/2015 |
| JUSTICE, DAVID | Individual | MANAGING CONTROL - GOVERNING BODY | since 04/01/2015 |
| KELSEY, DONNA | Individual | MANAGING CONTROL - GOVERNING BODY | since 07/18/2024 |
| STITLE, STEPHEN | Individual | MANAGING CONTROL - GOVERNING BODY | since 03/16/2016 |
| WRIGHT, THERESSA | Individual | MANAGING CONTROL - GOVERNING BODY | since 05/21/2021 |
| DRUMMER, CARL | Individual | CORPORATE DIRECTOR | since 01/01/2017 |
| HANIFY, THOMAS | Individual | CORPORATE DIRECTOR | since 01/01/2022 |
| HORN, BRENDA | Individual | CORPORATE DIRECTOR | since 12/01/2023 |
| LAZARD, ROBERT | Individual | CORPORATE DIRECTOR | since 01/29/2021 |
| MANTRAVADI, GEETA | Individual | CORPORATE DIRECTOR | since 07/21/2021 |
| PAYNE, MONICA | Individual | CORPORATE DIRECTOR | since 08/09/2021 |
| BABCOCK, PAUL | Individual | CORPORATE OFFICER | since 09/30/2020 |
| CAINE, VIRGINIA | Individual | CORPORATE OFFICER | since 01/10/1994 |
| HARRIS, LISA | Individual | CORPORATE OFFICER | since 12/22/2003 |
| AMERICAN SENIOR COMMUNITIES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/30/2026 |
| DICE, MARK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2023 |
| GINTER, ERIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/30/2026 |
| SHANE, ANDREW | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2023 |
| SINGLETON, MICHELLE | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 09/15/2021 |
| VAN CAMP, STEVEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2023 |
| WOLFRAM, DONALD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/30/2026 |
CMS files one row per role, so the 32 rows in the source record cover these 26 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner 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.
This home reported $1.1M paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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
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.
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 155784. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-31, 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 →
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