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Green Valley Care Center

3118 Green Valley Rd, New Albany, IN 47150 · Government - City/county · 141 certified beds · (812) 945-2341 Medicare & Medicaid certified

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Flagged for abuse1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)
Insights

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

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • CMS has flagged it for abuse
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Aug 2025
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (21) — 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 independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • about 84% 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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 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 3 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

Urgent care / clinic
720 Rolling Creek Dr · (812) 248-4789 · Call to confirm hours
Pharmacy
2910 Grant Line Rd · (812) 944-1214 · Call to confirm hours
Grocery
Aldi1.0 mi
3118 Grant Line Rd · (855) 955-2534 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased2.3%11.0%15.4%better
Long-stay residents who lose too much weight5.6%5.5%5.4%typical
Long-stay residents with a catheter left in their bladder0.8%0.4%0.9%typical
Long-stay residents with a urinary tract infection1.9%1.1%2.0%typical
Long-stay residents with depressive symptoms17.4%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 injury1.7%3.9%3.3%better
Long-stay residents whose ability to walk worsened3.3%11.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication24.1%23.5%18.9%worse
Long-stay residents given the seasonal flu vaccine98.3%95.4%95.3%typical
Long-stay residents with pressure ulcers2.8%3.6%4.7%better
Long-stay residents with worsening bladder/bowel control23.3%23.3%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table12.5%13.6%17.1%better
Short-stay residents who newly got an antipsychotic medication1.3%1.2%1.4%typical
Short-stay residents given the seasonal flu vaccine76.1%79.0%79.4%typical
Short-stay residents rehospitalized after admission19.4%22.2%22.6%better
Short-stay residents with an outpatient ER visit3.9%10.8%12.0%better
Long-stay hospitalizations per 1,000 resident days1.721.611.67typical
Long-stay outpatient ER visits per 1,000 resident days0.381.441.80better

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

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

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

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

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

48.8% 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 96 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

48.8%U.S. median 51.5%
Got home and stayed home
11.4%U.S. median 10.7%
Went back to hospital
61.1%U.S. median 56.6%
Met the expected recovery
0.35U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 61.1% 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 54 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 0.35 therapist hours per resident per day in 2026Q1 — more than 60% 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 SNF48.8%CMS range 39.9–56.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.4%CMS range 8.1–15.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge61.1%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 discharge70.4%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 discharge63.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.4%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 hospitalization7.5%CMS range 4.4–13.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.081.02Oct 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

0.37
RN hours/ resident / day
1.15
LPN hours/ resident / day
2.09
Aide hours/ resident / day
3.61
Total nurse hours/ resident / day
0.18
RN hoursweekends
40.8%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 141 beds and averages 119.4 residents a day — about 85% occupied, or roughly 22 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 3.61 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.37 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.09 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 3.27 hrs/resident/day on weekends vs 3.75 on weekdays — 13% thinner on weekends. RN hours go from 0.45 to 0.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% 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 (2026-01-09)
0
at the previous standard inspection (2024-11-06)

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.

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

  • Actual harm · G2023-08-21 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents were free of significant medication errors which resulted in Resident D being hospitalized for hypoglycemia after receiving an anti-diabetic medication without a diagnosis of diabetes for 1 of 3 resident's whose medication regimens were reviewed. Findings include: The record for Resident D was reviewed on 8/21/23 at 10:00 a.m. The resident did not have any diagnoses related to or including diabetes. The record lacked documentation of any blood sugar monitoring orders or blood glucose levels in the last 12 months prior to 5/11/23. The physician's order, dated 5/11/23 at 5:42 p.m., indicated RN 4 input an order for the resident to have glipizide (anti-diabetic medication) 5 mg (milligrams) daily for diabetes. NP (Nurse Practitioner) 3 signed off on the order on 5/12/23 at 12:45 p.m. The order note, dated 6/30/23 at 11:52 a.m., indicated the resident was prescribed Bactrim DS (double strength) tablet 800-160 mg 1 tablet daily for a UTI…

    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 · Past Non-Compliance
  • Potential for harm · Fcited before2026-01-09 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure kitchen equipment, floors, ceiling vents were clean and in good condition and expired food was disposed of during 3 of 3 kitchen observations. This deficient practice affected 122 of 122 residents who received meals from the kitchen.Findings include:1.During the initial tour of the kitchen with [NAME] 1, on 1/5/26 at 10:00 a.m., the following concerns were observed:There were yellow/brown food particles in the fryer oil with a heavy accumulation of brown food particles on the inside shelf. Cook,1 indicated the fryer was last used the night before.Both stove ovens had cream colored food particles on the inside bottom. The outside doors of the oven and handles were sticky to the touch and had a heavy accumulation of white streaks running down the front doors.Around 3 sides of the fryer there were white and brown sticky streaks.The left side of the convection oven had yellow grease particles on it and felt greasy to the touch.The top and bottom of the convection ovens had brown and white streaks running…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-01-09 · 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, record review, and interview, the facility failed to ensure proper labeling on 6 of 24 residents receiving insulin during the review of medication storage. (Residents 28, 9, 2, 4, 115 and 23) Findings include: 1. During an observation of the 300 Hall medication cart, on 1/7/26 at 8:41 a.m., the following concerns were identified for Resident 28: a. Resident 28's Lispro (rapid acting insulin) had no pharmacy label with the KwikPen in the medication cart or in the refrigerator. b. Resident 28's Rezvoglar (long-acting insulin) had no pharmacy label with the KwikPen in the medication cart or in the refrigerator. The record for Resident 28 was reviewed on 1/8/26 at 10:08 a.m. The diagnoses included, but were not limited to, protein-calorie malnutrition, type 2 diabetes mellitus with diabetic neuropathy, stage 3 chronic kidney disease, and anemia. The care plan, dated 12/18/25, indicated the resident had a diabetes mellitus diagnosis and was at risk for abnormal blood sugar readings. The interventions, dated 12/18/25, included, but were not limited to, blood sugar…

    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 · E2026-01-09 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure proper Personal Protective Equipment (PPE) was applied and the catheter bag drainage valve was kept off of the floor to prevent infection during 2 of 3 observations of care. (Residents 7 and 82) and to ensure glucometers were cleaned per guidelines for infections control when obtaining blood sugar readings for 2 of 2 residents observed. (Residents 32 and 2)Findings include:1. During an observation, on 1/6/26 at 9:38 a.m., Certified Nurse Aide (CNA) 5 entered Resident 7's room to empty the catheter bag, which was full of light-yellow urine and bulging. The urine was visible in the line leading up to the resident. She emptied the bag four to five times before it was empty. She applied gloves but did not apply a gown for Enhanced Barrier Precautions (EBP). There was signage on the entry door indicating the resident was in EBP related to wound and catheter care. The equipment to be worn during care, were indicated on the signage for gloves and a gown. During an interview, on 1/6/26 at 9:41 a.m., Resident 7…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-09 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a resident with a history of Urinary Tract Infection (UTIs) was provided proper management of the urinary catheter drainage system by maintaining the drainage system with sufficient emptying of the drainage system for 1 of 1 residents reviewed for catheter care. (Resident 7) Findings include:During an observation, on 1/5/26 at 10:01 a.m., Resident 7's catheter bag was full of urine and bulging. Urine was observed leading up the tubing to the resident. The urine was clear light yellow. The floor was sticky when walking on it. During an interview, on 1/6/26 at 9:24 a.m., Resident 7 indicated the catheter bag broke open and the urine was everywhere. The staff had mopped up the urine on the floor today. During an observation, on 1/6/26 at 9:38 a.m., Certified Nurse Aide (CNA) 5 entered the resident's room to empty the catheter bag which was full of light-yellow urine and bulging. The urine was visible in the line leading up to 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 · D2026-01-09 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    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 ensure residents were free of a medication error rate greater than 5 percent for 2 of 24 opportunities, resulting in a medication error rate of 8.33%. (Resident 32 and Resident 2)Findings include:1. During an interview, on 1/7/26 at 11:15 a.m., the Licensed Practical Nurse (LPN) 3 indicated that she had already checked Resident 32's blood glucose. She indicated the reading was 244 milligrams per deciliter (mg/dL) and after reviewing the physician's order it was determined that the resident would get 4 units of insulin Lispro Injection subcutaneously. During an observation, on 1/7/26 at 11:25 a.m., LPN 3 performed hand hygiene, primed the Lispro Insulin pen with 2 units without the needle intact at the time of priming. The needle was then put on the insulin pen; the LPN went to the resident's room and cleaned the lower right abdomen with alcohol and did not allow it to dry. LPN 3 injected the insulin and left it place for only 4 seconds before retracting the insulin pen. Review of the manufacturer requirements…

    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 before2025-08-05 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from misappropriation of medications for 1 of 4 residents reviewed for misappropriation. (Resident D)Findings included: The record for Resident D was reviewed, on 8/4/25 at 12:37 p.m. The diagnoses included, but were not limited to, anxiety disorder, bipolar disorder, generalized anxiety disorder, unspecified intellectual disabilities, major depressive disorder, front-temporal neurocognitive disorder, and dementia. The Quarterly Minimum Data Set (MDS) Assessment, dated 5/12/25, indicated the resident was severely cognitively impaired. The review of the incident report, dated 7/27/25, indicated a staff member was suspected of taking narcotic medications from the resident for her personal use. The staff member involved was a Licensed Practical Nurse (LPN). During an interview on 8/4/25 10:13 a.m., Certified Nurse aide 4 (CNA) indicated that the resident does not show signs of pain most of the time, but does get agitated from…

    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
  • Potential for harm · E2025-06-04 · tag F0628 — pattern
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure bed hold polices were provided to residents/resident representatives ( Resident C, Resident D, Resident F and Resident B) discharged to the hospital for 4 of 4 residents reviewed for transfers/discharges. Findings include: 1. The clinical record for Resident C was reviewed on 6/4/25 at 11:31 a.m. The resident's diagnoses included, but were not limited to, paraplegia and neuromuscular dysfunction of the bladder. The progress note, dated 5/26/25 at 1:00 a.m., indicated the resident was very lethargic and the catheter had blood tinged urine in the catheter bag. The physician was notified and a new order was received to send the resident to the hospital for evaluation. The clinical record lacked documentation of the bed hold documentation provided to the resident or the resident's representative at the time of discharge. 2. The clinical record for Resident D was reviewed on 6/4/25 at 2:49 p.m. The resident's diagnoses included, but were not limited…

    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 · D2025-06-04 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the physician's orders were in place for weekly maintenance of nebulizer equipment and failed to ensure nebulizer respiratory assessments were completed prior and after administration for 1 of 3 residents reviewed for respiratory care. Findings include: The clinical record for Resident B was reviewed on 6/4/24 at 9:54 a.m. The resident's diagnosis included, but was not limited to, chronic obstructive pulmonary disease. Review of the December 2024 medication administration record (MAR) indicated the resident received pulmicort 0.5 mg (milligrams)/2 ml (milliliters). The resident was to received 2 ml, via nebulizer, twice daily. The resident's clinical record lacked documentation of the December weekly replacement of the nebulizer respiratory equipment. Review of the January 2025 MAR indicated the resident received pulmicort 0.5 mg (milligrams)/2 ml (milliliters). The resident received 2 ml, via nebulizer, twice daily upon readmission…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-21 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure staff to resident abuse did not occur for 1 of 3 residents reviewed for abuse. (Resident B) Findings include: The clinical record for Resident B was reviewed on 8/20/24 at 11:43 a.m. The resident's diagnosis included, but was not limited to, dementia. The incident report, dated 6/24/24 at 11:20 p.m., indicated Resident B was being assisted with toileting needs by CNA 4 when Resident B bit the side of CNA 4's arm. CNA 4 reported she made contact with Resident B's facial area in an attempt to stop the biting process. The written statement from CNA 4, dated 6/25/24 at 11:07 a.m., indicated Resident B was sitting in the dining room eating a snack and had been restless. On 6/24/24 at 11:30 p.m., CNA 4 tried to get the resident up to provide incontinent care but the resident was resistant and held onto the chair arms. CNA 4 waited a couple of minutes and tried again. CNA 4 leaned in and put her hand on the resident's waistline to help her up at that time the resident bit her right inner upper arm. Out of reflex, CNA 4…

    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
  • Potential for harm · Ecited before2024-07-25 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure the kitchen equipment and floor was clean and free from grease and food particles for 2 of 3 kitchen observations. This deficient practice had the potential to affect 120 residents currently residing in the facility. Findings Include: During an observation of the facility kitchen the following was observed: - The deep fryer had grease and a brown black substance buildup on the fryer baskets, and the top and sides of the fryer. - The gas stove knobs had a grease and food debris buildup. - The cart sitting beside the stove, had a sheet pan sitting on the shelf with a greasy food buildup on the utensils. - The employee sink had a black substance in the sink bowl, and on the front and sides of the sink. - The kitchen floor felt greasy and was slippery. The floor was dirty with grime and food debris build up. There were various items of trash laying on the floor. - Sitting on a table near the dishwasher there was a large bowl with a brown thick substance inside. The substance was up the sides of the bowl and…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · Dcited before2024-04-30 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure misappropriation of resident property did not occur for 1 of 3 residents reviewed for misappropriation. (Resident D) Findings include: The clinical record for Resident D was reviewed on 4/29/24 at 12:21 p.m. The resident's diagnoses included, but were not limited to, depression, anxiety and pain. The physician's order, dated 4/17/24, indicated Resident D was to receive Oxycodone (narcotic pain medication) 5 mg (milligrams), one half of a tablet (2.5 mg) twice a day and every 4 hours as needed for pain. The internal facility incident report, dated 4/23/24 at 4:05 p.m., indicated Resident D was missing one card with 22.5 tablets of Oxycodone and one narcotic count sheet. The Oxycodone was sent to the facility, from the pharmacy on 4/19/24. All statements had been obtained from staff that worked the medication cart except for QMA (Qualified Medication Aide) 9. The State incident report, dated 4/26/24, indicated a narcotic discrepancy had been identified on the Memory Care Unit for Resident D. The pharmacy delivery…

    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 · D2024-01-29 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure food served was maintained at an appropriate temperature for 1 of 1 Hall tray carts observed for food temperatures. (300 Hall Cart) Findings include: On 1/29/24 at 12:58 p.m., during an observation of the lunch meal pass on the 300 Hall with the Dietary Manager, the following food temperatures were observed: - Beef Stew - 110 degrees - Fried tomatoes - 110 degrees - Biscuit - 100 degrees During an interview on 1/29/24 at 2:00 p.m., Resident E indicated that a lot of times, the food served was barely warm. During an interview on 1/29/24 at 2:20 p.m., Resident F indicated that 40 % (percent) of the time, the food was just not warm. Breakfast was the worst because no one wants to eat cold eggs. On 1/29/24 at 2:30 p.m., Resident H indicated she liked her food hot, but when they brought it to her, it had minimal warmth. On 1/29/24 at 2:38 p.m., Resident G indicated she liked her food served hot. The food was not even warm by the time she received it in her room. On 1/29/24 at 3:04 p.m., the Executive Director provided 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-10 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to schedule 8-hour consecutive RN coverage for 3 of 3 months reviewed. (August, September and October 2023). This had the potential to affect all 113 residents currently residing in the facility. Findings include: The review of the August through October 2023 Licensed Nursing schedule indicated the following days were short of 8 hours consecutive RN coverage: August: Sunday 8/6 = only 6.0 hours Saturday 8/12 = only 6.0 hours Sunday 8/13 = only 6.0 hours Sunday 8/20 = only 6.0 hours Saturday 8/26 = only 6.0 hours Sunday 8/27 = only 6.0 hours September: Saturday 9/2 = only 6.0 hours Sunday 9/3 = only 6.0 hours Saturday 9/9 = only 6.0 hours Sunday 9/10 = only 6.0 hours Saturday 9/16 = only 6.0 hours Sunday 9/17 = only 6.0 hours Saturday 9/23 = only 6.0 hours Sunday 9/24 = only 6.0 hours October: Sunday 10/1 = only 6.0 hours During an interview with the Director of Nursing on 10/5/23 at 3:30 p.m., she indicated she was aware of the RN coverage being short on the weekends and indicated they were trying to add more RNs to cover 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-10 · 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, record review, and interview, the facility failed to ensure appropriate storage and labeling of medications for 3 of 4 medication carts observed for medication storage and labeling. (100 Hall Front Medication Cart, 100 Hall Back Medication Cart, and 200 Hall Front Medication cart) Findings include: 1. During an observation of the 100 Hall Front Medication Cart on 10/6/23 at 11:05 a.m., the following concerns were observed: a. Resident 58's albuterol sulfate 90 mcg/act (micrograms per actuation) inhaler was stored lying on its side. The medication packaging storage instructions indicated to store the inhaler with the mouthpiece down. The record for Resident 58 was reviewed on 10/6/23 at 11:45 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD) and asthma. The physician's order, dated 5/21/23, indicated the resident received albuterol sulfate 108 (90 mcg base) every 6 hours as needed for COPD. b. There were two unlabeled bottles of lidocaine 200 mg/20 mL (milligrams per milliliters) lying in the top drawer. One of…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-10 · tag F0943 — pattern
    Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
    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 staff completed dementia training for 8 of 10 employee records reviewed. Findings include: The Employee Records were reviewed on 10/6/23 and 10/10/23. The following staff had not completed their required initial and/or annual dementia training: - Laundry Aide 3 was hired on 1/30/12. The Laundry Aide's employee record lacked the annual 3 hours dementia training - CNA (Certified Nurse Aide) 4 was hired on 2/15/23. The CNA's employee record lacked the initial 6 hours dementia training - CNA 5 was hired on 10/11/18. The CNA's employee record lacked the annual 3 hours dementia training - CNA 6 was hired on 1/24/23. The CNA's employee record lacked the initial 6 hours dementia training - ADON (Assistant Director of Nursing)/RN 2 was hired on 4/4/23. The ADON's employee record lacked the initial 6 hours dementia training - RN 7 was hired on 12/13/16. The RN's employee record lacked the annual 3 hours dementia training - QMA (Qualified Medication Aide) 9 was hired on 1/21/21. The QMA's employee record lacked the annual 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-10 · 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, record review, and interview, the facility failed to provide coverage and odor protection for a resident related to expressed embarrassment for 1 of 5 residents reviewed for dignity. (Resident 260) Findings include: During an observation, on 10/5/23 at 8:00 a.m., the resident's dressing to her left shoulder was laying in the bed. The malignant tumor was exposed. The resident indicated she wrapped a towel around the tumor to catch the drainage. The pad on the resident's bed was soaked with serosanguineous drainage. The dressing was not dated but the time indicated 6:00 a.m. The resident indicated she did not get out of her room much, but she thought she should. During an observation, on 10/5/23 at 10:00 a.m., the resident was sitting on the side of the bed and her tumor was exposed. The dressing remained in the resident's bed. During an observation, on 10/5/23 at 10:30 a.m., LPN (Licensed Practical Nurse) 12 was providing wound care. She wrapped the tumor in a warm towel and left it on for about 15 minutes. The resident indicated the warm towel felt good to her.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-10 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure treatment and interventions were provided for 1 of 5 residents reviewed for Quality of Care. (Resident 260) Findings Include: During an observation on 10/04/23 at 8:30 a.m., Resident 260's dressing to her left shoulder was saturated with a large amount of serosanguineous drainage, bright red blood, and dried dark colored blood. The dressing was falling off in places. The dressing had a foul odor and the resident indicated her dressing had not been changed. The resident indicated the odor had improved slightly but the wound still had a bad odor. The serosanguinous drainage was observed on the pad in her bed. During an observation on 10/04/23 at 11:00 a.m., Resident 260's dressing to her left shoulder was saturated with a large amount of serosanguineous drainage, bright red blood, and dried dark colored blood. The dressing was loose and was falling off in places. The dressing had a foul odor and the resident indicated her dressing had not been changed yet. During an observation on 10/04/23 at 1:00 p.m.,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-10 · 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

    Based on observation, record review, and interview, the facility failed to develop and implement appropriate interventions to prevent falls for 1 of 5 residents reviewed for falls. (Resident 55) Findings include: The record for Resident 55 was reviewed on 10/5/23 at 8:11 a.m. The diagnoses included, but were not limited to, displaced intertrochanteric fracture of left femur, lack of coordination, muscle weakness, unsteadiness on feet, need for assistance with personal care, cognitive communication deficit, dementia, overactive bladder, history of falling, and pain in right hip. The care plan, dated 5/21/22, indicated the resident had bowel and bladder incontinence at times and was at risk for skin breakdown and infection with ongoing incontinence. The intervention, initiated on 7/14/22, indicated staff were to check the resident every 2 hours and assist with toileting as needed. The Annual MDS (Minimum Data Set) Assessment, dated 4/19/23, indicated the resident was moderately cognitively impaired,usually incontinent of urine and always continent of bowel, and required extensive…

    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 · D2023-10-10 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    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 urine and blood work were sent to the laboratory for testing as ordered by the physician for 1 of 3 residents reviewed for laboratory testing. (Resident 45) Findings include: The record for Resident 45 was reviewed on 10/4/23 at 9:31 a.m. The diagnoses included, but were not limited to, benign prostatic hyperplagic (BPH) without lower urinary tract symptoms, retention of urine, muscle weakness, rhabdomyolysis, hypertensive ischemic heart disease, and supraventicular tachycardia. The Quarterly Minimum Data Set (MDS) assessment, dated 9/26/23, indicated the resident had severe cognitive impairment; required extensive assist of 2 staff for bed mobility, transfers and toilet use; was non-ambulatory; was frequently incontinent of bladder; and had bilateral lower and upper impairments in functional range of motion. A care plan, initiated on 6/29/19 and revised on 8/3/21, indicated the resident had an altered cardiovascular status related to coronary artery disease and hyperlipidemia. The goal indicated the resident…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-21 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the kitchen was maintained in a sanitary manner, disposal of expired food, and maintain repairs for 2 of 2 observations. This deficient practice had the potential to affect all 118 residents currently residing at the facility. Findings include: During the initial tour of the kitchen on 8/21/23 at 9:20 a.m., the following concerns were observed: - The paper towel dispenser was not working and there was no trash can by the sink for disposal of the paper towels. - One knife, two plastic tray lids, and several plastic bowl covers were on the floor under steam table and coffee table. - In the reach in fridge there were several salads dated 8/20, unidentifiable leftovers dated 8/20/23, mashed potatoes dated 8/20/23, and several sandwiches in the bin were dated 8/22. - The Dietary [NAME] 7 indicated the leftovers were dated on the date they were prepared; the sandwiches had the expiration date 8/22/23. - Inside the walk in refrigerator, a container of…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to LIFE CARE CENTERS OF AMERICA — 194 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 3 of 53.4-0.4 vs chain
Health inspection 2 of 52.8-0.8 vs chain
Staffing 2 of 53.3-1.3 vs chain
Quality measures 5 of 54.5+0.5 vs chain
The other 193 homes this chain runs (chain average 3.4★, per CMS)
1 of 5Garden Terrace At Overland ParkOverland Park, KS 1 of 5Hammond-Whiting Care CenterWhiting, IN 1 of 5Life Care Center Of AndoverAndover, KS 1 of 5Life Care Center Of Cape GirardeauCape Girardeau, MO 1 of 5Life Care Center Of GrayGray, TN 1 of 5Life Care Center Of HixsonHixson, TN 1 of 5Life Care Center Of Mount VernonMount Vernon, WA 1 of 5Life Care Center Of RenoReno, NV 1 of 5Life Care Center Of Sierra VistaSierra Vista, AZ 1 of 5Life Care Center Of The WillowsValparaiso, IN 1 of 5Life Care Center Of TucsonTucson, AZ 1 of 5Life Care Center of Coeur d'AleneCoeur d'Alene, ID 1 of 5Life Care Center of ElkhornElkhorn, NE 1 of 5Life Care Center of Hilton HeadHilton Head Island, SC 1 of 5Life Care Center of OmahaOmaha, NE 1 of 5Life Care Center of PlainwellPlainwell, MI 1 of 5Life Care Ctr Of LawrencevilleLawrenceville, GA 1 of 5Rensselaer Care CenterRensselaer, IN 2 of 5Canon Lodge Care CenterCanon City, CO 2 of 5Darcy Hall Of Life CareWest Palm Beach, FL 2 of 5Desert Cove Nursing CenterChandler, AZ 2 of 5Evergreen Nursing HomeAlamosa, CO 2 of 5Garden Terrace Healthcare Center of HoustonHouston, TX 2 of 5Hallmark ManorFederal Way, WA 2 of 5Lane House, TheCrawfordsville, IN 2 of 5Life Care Center Of Altamonte SpringsAltamonte Springs, FL 2 of 5Life Care Center Of AthensAthens, TN 2 of 5Life Care Center Of BridgetonBridgeton, MO 2 of 5Life Care Center Of BrookfieldBrookfield, MO 2 of 5Life Care Center Of ClevelandCleveland, TN 2 of 5Life Care Center Of ColumbiaColumbia, SC 2 of 5Life Care Center Of Coos BayCoos Bay, OR 2 of 5Life Care Center Of Federal WayFederal Way, WA 2 of 5Life Care Center Of GrandviewGrandview, MO 2 of 5Life Care Center Of KirklandKirkland, WA 2 of 5Life Care Center Of Merrimack ValleyBillerica, MA 2 of 5Life Care Center Of Morgan CountyWartburg, TN 2 of 5Life Care Center Of PuyallupPuyallup, WA 2 of 5Life Care Center Of Red BankChattanooga, TN 2 of 5Life Care Center Of South Las VegasLas Vegas, NV

Showing 40 of 193; 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 / managerTypeRoleSince
ENGELS, ERINIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 12/01/2018
STARKEY, TYLERIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 08/01/2020
WAITE, JOHNIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 08/01/2020
WHICKER, TIMOTHYIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 01/12/2022
FENOUGHTY, DEANNAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 07/10/2023
CONSOLIDATED RESOURCES HEALTH CARE FUND I LPOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2018
LIFE CARE CENTERS OF AMERICA, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/17/2025
DATTILO, GREGORYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/09/2021
FLETCHER, TODDIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2018
HENRY, TERRYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2018
LAY, LISAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2018
PRESTON, AUBREYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 03/06/2025
PRESTON, FORRESTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2018
SALCEDO, FEDERICOIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/09/2016
SWANKER, RICHARDIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2018
THURMOND, JOANIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2018
ZIEGLER, JAMESIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2018
GENTRY, MARKIndividualTRUSTEE OF THE SNFsince 01/12/2022
HENDRICKS COUNTY HOSPITALOrganizationADP OF THE SNFsince 02/28/2025

CMS files one row per role, so the 29 rows in the source record cover these 19 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.

$15.9M
Net patient revenuemost recent cost report
+2.7%
Operating marginrevenue minus expenses
$13.1M
Related-party expense84% of expenses
Who pays — share of resident-days
Medicaid 67%Medicare 10%Other / private 23%

This home reported $13.1M paid to related parties — landlords or management companies under common ownership — equal to about 84% 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

$361per resident / day
operating cost
$10,989per month
≈ monthly operating cost
$372per 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 155070. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-09, 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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