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Hamilton Grove

31869 Chicago Trail, New Carlisle, IN 46552 · Non profit - Church related · 85 certified beds · (574) 654-2200 Medicare & Medicaid certified

Call the home — (574) 654-2200 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0744)1 actual-harm citation1 Medicare payment denial
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (29) — 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

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

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

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

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
 
Pharmacy
8989 US-20 · (574) 654-3148 · Call to confirm hours
Grocery
485 E Michigan St · (574) 654-7422 · Call to confirm hours
Park
ESTN Central Time Zone Bdy · Typically dawn to dusk
Place of worship
201 W Michigan St · (574) 654-3344

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 4 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 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased30.6%11.0%15.4%worse
Long-stay residents who lose too much weight5.6%5.5%5.4%typical
Long-stay residents with a catheter left in their bladder0.0%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.9%1.1%2.0%typical
Long-stay residents with depressive symptoms1.3%25.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury3.1%3.9%3.3%typical
Long-stay residents whose ability to walk worsened23.7%11.9%16.1%worse
Long-stay residents on antianxiety or hypnotic medication13.0%23.5%18.9%better
Long-stay residents given the seasonal flu vaccine89.8%95.4%95.3%typical
Long-stay residents with pressure ulcers4.7%3.6%4.7%typical
Long-stay residents with worsening bladder/bowel control25.2%23.3%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table17.2%13.6%17.1%typical
Short-stay residents who newly got an antipsychotic medication3.7%1.2%1.4%worse
Short-stay residents rehospitalized after admission10.8%22.2%22.6%better
Short-stay residents with an outpatient ER visit3.4%10.8%12.0%better
Long-stay hospitalizations per 1,000 resident days0.621.611.67better
Long-stay outpatient ER visits per 1,000 resident days0.481.441.80better

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.

52.6% 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 47 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

52.6%U.S. median 51.5%
Got home and stayed home
10.9%U.S. median 10.7%
Went back to hospital
0.26U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.26 therapist hours per resident per day in 2026Q1 — more than 38% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% 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 SNF52.6%CMS range 40.9–61.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.9%CMS range 7.4–16.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified95.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF 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 worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.021.02Oct 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

0.81
RN hours/ resident / day
0.83
LPN hours/ resident / day
2.40
Aide hours/ resident / day
4.04
Total nurse hours/ resident / day
0.67
RN hoursweekends
51.1%
Total nursing turnover
37.5%
RN turnover

How full it usually is: this home is certified for 85 beds and averages 45.6 residents a day — about 54% occupied, or roughly 39 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.04 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.81 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.40 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 3.64 hrs/resident/day on weekends vs 4.20 on weekdays — 13% thinner on weekends. RN hours go from 0.87 to 0.67 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 51% 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

4
deficiencies at the latest standard inspection (2025-05-08)
8
at the previous standard inspection (2024-05-06)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.

  • Actual harm · Gcited before2024-07-03 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to prevent unstageable pressure ulcers from developing and failed to provide necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing on the bilateral heels of a resident who was admitted without pressure ulcers, for 1 of 3 residents review for pressure ulcers. (Resident C) This deficient practice resulted in the development of a facility-acquired Deep Tissue Injury (DTI) on the left heel that deteriorated to an unstageable pressure injury and the development of a facility-acquired Deep Tissue Injury (DTI) and DTI on the right heel that deteriorated to a stage three pressure injury with signs and symptoms of infection and required debridement. Findings include: The record for Resident C was reviewed on 6/28/2024 at 12:05 P.M. Diagnoses include, but were not limited to, multiple sclerosis (MS), edema, neuropathy, and hypertension A Quarterly Minimum Data Set (MDS) Assessment, dated 3/1/2024, indicated the resident was cognitively intact, had bilateral lower extremity…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-09 · 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 wound treatments were in place as ordered and neurological checks were completed following a fall for 1 of 3 residents reviewed for non-pressure skin conditions and 1 of 3 residents reviewed for falls. (Resident B)Finding includes: On 6/8/26 At 1:10 p.m., Resident B was observed in her room with CNA 1. CNA 1 lifted the resident's pant leg and removed her sock so the resident's wounds could be observed on the right lower leg and left heel. Neither wound had a dressing in place, both were open to air. During an interview at the time, CNA 1 indicated she was unaware if the resident required any dressings to the wounds.Resident B's record was reviewed on 6/8/26 at 11:00 a.m. The diagnoses included, but were not limited to, dementia, heart failure, COPD, kidney disease stage 3, panic disorder, history of falling, anemia (low iron), depression, and macular degeneration (vision loss).The Annual Minimum Data Set (MDS) assessment, dated 3/26/26, indicated the resident was severely impaired for daily decision…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-03 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the responsible party for 1 of 3 residents reviewed for discharge from the facility, received in writing, a Notice of Medicare Non-Coverage including the date of discharge. (Resident B) Finding Includes:On 12/1/25 at 1:14 P.M., Resident B's clinical record was reviewed. Resident B was admitted to the facility on [DATE] and discharged home with family on 11/8/25. The residents' diagnoses included but were not limited to a fractured sacrum, chronic bronchitis, chronic obstructive pulmonary disease, repeated falls, altered mental status, depression, anxiety, and liver cancer.A facility admission Agreement form, dated 9/3/22 and signed by the facility Area Marketing Liaison and Resident B's family member on 10/3/25, indicated the family member was Resident B's Resident Representative. The admission Agreement indicated the Resident Representative was an individual the Resident had chosen to act on his or her behalf to support decision making; access…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-03 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure a discharge care plan was created for 1 of 3 residents reviewed for discharge planning. The facility also failed to ensure the Resident's Responsible Party was invited to participate in the care planning process for their family member for 1 of 3 resident reviewed for discharge planning. (Resident B).Finding Includes:On 12/1/25 at 1:14 P.M., Resident B's clinical record was reviewed. Resident B was admitted to the facility on [DATE] and discharged home with family on 11/8/25. The residents' diagnoses included but were not limited to a fractured sacrum, chronic bronchitis, chronic obstructive pulmonary disease, repeated falls, altered mental status, depression, anxiety, and liver cancer.A facility admission Agreement form, dated 9/3/22 and signed by the facility Area Marketing Liaison and Resident B's family member on 10/3/25, indicated the family member was Resident B's Resident Representative. The admission Agreement 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-08 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to notify a Physician of a resident's change in condition related to blood pressures and missed doses of medication for 2 of 5 residents who were reviewed. (Resident 3 and 30 Findings include: 1. Resident 3's record review was completed on 5/6/2025 at 8:53 A.M. Diagnoses included, but were not limited to: dementia, major depressive disorder, generalized anxiety disorder, hypercholesterolemia, supravalvular aortic stenosis, peripheral vascular disease, atrial fibrillation, nonrheumatic mitral valve disease and hypertension. Current Physician's orders indicated Resident 3 was to receive 2.5 milligrams (mg) of olanzapine (treats symptoms of mental health disorders), 10 mg of melatonin (sleep aid) and 40 mg of pravastatin (treats high cholesterol) at bedtime. A review of the April 2025 Medication Administration Record (MAR) indicated Resident 3 had refused her bedtime medications of olanzapine, melatonin and pravastatin on 4/8/2025. In addition, Resident 3 had not received her bedtime doses of olanzapine, melatonin or pravastatin…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-08 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure adequate monitoring of antipsychotic medications occurred medications timely for 2 of 3 residents who were reviewed for antipsychotic medications . (Resident 3 and 18) Findings include: 1. Resident 3's record review was completed on 5/6/2025 at 8:53 A.M. Diagnoses included, but were not limited to: dementia, major depressive disorder, generalized anxiety disorder, hypercholesterolemia, supravalvular aortic stenosis, peripheral vascular disease, atrial fibrillation, nonrheumatic mitral valve disease and hypertension. A current Physician's order indicated Resident 3 received 2.5 mg of olanzapine (antipsychotic medication that treats symptoms of mental disorders) once a day at bedtime. Resident 3 had an AIMS (Abnormal Involuntary Movement Scale) assessment on 12/2/2024. There was no documentation to indicate another AIMS assessment had been completed after 12/2/2024 and before 5/6/2025. During an interview on 5/5/2025 at 2:20 P.M., the Director of Nursing indicated the facility's policy was to perform an AIMS…

    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 before2025-05-08 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to store food in a sanitary manner related to labeling and dating opened food and disposing of expired food in 1 of 1 kitchen that was reviewed. This deficient practice had the potential to affect 49 of the 49 residents who received their meals from the kitchen. Finding includes: During an observation of the kitchen on 4/30/2025 at 8:15 A.M. with the Certified Dietary Manager (CDM), the following foods were in the walk-in cooler, but were expired or had no opened on or use by date: - 1 package of smoked turkey dated 4/14/2025 - 1 container with cut up purple onion dated 4/20/2025 - 1 container of premade chicken salad dated 4/22/2025 - 1 package of Virginia ham dated 4/21/2025 - A container with cut up white onion dated 4/21/2025 During an observation of the kitchen with the CDM on 4/30/2025 at 8:20 A.M., the following was observed: - Leaf tarragon was open but did not have an opened on or use by date. - Ranch powder was open but did not have an opened on or use by date. - Red food coloring was open but did not…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-08 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to provide a sanitary environment related to disposing of expired food in a resident's personal refrigerator for 1 of 3 personal refrigerators observed. Finding includes: During an observation on 4/30/2024 at 9:51 A.M. of Resident 3's personal refrigerator, the following was observed: - A container of parmesan cheese with an expiration date of 11/2023 - A single serve cup of chocolate pudding with an expiration date of 7/3/2024. - A single serve cup of vanilla pudding with an expiration date of 11/24/2024. - Two cups of juice were covered with no date. The juice in both cups had separated and a large buildup of a thick white substance covered the top third of the juice glasses. - One bowel with a lid that contained no made on or use by date. The food in the bowel had mold and was unidentifiable. During an interview on 4/30/2024 at 9:55 A.M., RN 2 indicated she was not sure whose responsibility it was to clean out resident's personal refrigerators. She indicated expired food should not be in the resident's…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-22 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure medication and supplement orders were accurately transcribed and medications were administered timely to 2 of 3 residents reviewed for medication orders. (Resident C and J) Findings include: 1. The record for Resident C was reviewed on 10/21/2024 at 11:00 A.M. Diagnoses included but were not limited to, chronic obstructive pulmonary disease, diastolic congestive heart failure and left ventricular heart failure. A Physician's Order, dated 7/23/2024, indicated the resident's Lasix (a diuretic medication) was to be increased to 80 mg per day. The Medication Administration Records (MARs) for July 2024 and August 2024 indicated the order was documented on the administration record, but the resident only received the medication twice, on 7/27 and 8/3. On 8/13/2024 the Nurse Practitioner (NP) reordered 80 mg of Lasix medication per day. Another order, dated 9/18/2024, indicated to increase Occuvite (a vitamin supplement) to twice daily. The September…

    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 · Ecited before2024-05-06 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to develop person-centered care plans for activities, behaviors, ADLs (activities of daily living), and dementia care for 4 of 15 residents whose care plans were reviewed. (Residents 25, 23, 36 and 53) Findings include: 1. During a random observation on 4/30/2024 at 11:21 A.M., Resident 25 was not seen in an activity. During an observation, on 4/30/2024 at 1:19 P.M., Resident 25 was in bed sleeping, there was a small clock radio sitting on a dresser across the room, there was no television in the room. A record review was completed on 5/1/2024 at 2:22 P.M. for Resident 25. Her diagnoses included, but were not limited to, dementia, anxiety, depression, psychotic disorder and bipolar. An Annual MDS (Minimum Data Set) assessment, dated 5/31/2023, indicated it was not very important to her to have books, magazines, newspapers to read and it was somewhat important to listen to music she liked. A Quarterly MDS assessment, dated 2/18/2024,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-06 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record reviews, and interviews, the facility failed to provide activities of daily living (ADLs) for 1 of 4 residents reviewed for activities of daily living. (Resident 36) Finding includes: During an observation, on 4/29/2024 at 11:11 A.M., Resident 36 was noted to not have been shaved and his fingernails were long with brownish yellow matter under them. During an observation on 5/1/2024 at 9:10 A.M., Resident 36 was still not shaved and his fingernails were long. A record review for Resident 36 was conducted on 5/1/2024 2:18 P.M. Diagnoses included, but were not limited to, Alzheimer's, dementia, major depressive disorder, general anxiety disorder, and psychotic disorder with delusions. An Annual Minimum Data (MDS) assessment, dated 2/1/2024, indicated no response to the question regarding cognition. No behavior concerns were noted. He was dependent for bathing, hygiene, and dressing. He needed set up help for bed mobility, transfers and walking A Care Plan indicated Resident 36 had an actual or potential problem with activities of daily living (ADLs)…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · Dcited before2024-05-06 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During an observation, on 4/30/2024 at 11:21 A.M., Resident 25 was observed in her room sleeping. During an observation, on 4/30/2024 at 1:19 P.M., Resident 25 was in bed sleeping. A record review was completed on 5/1/2024 at 2:22 P.M. Resident 25's diagnose included, but were not limited to heart failure, dementia, seizures, anxiety, depression, psychotic disorder and bipolar. A Quarterly MDS (Minimum Data Set) Assessment, dated 2/18/2024, indicated the resident had a severe cognitive impairment. Had delusions and physical behaviors and received antipsychotics, antidepressants and antianxiety medications. A current Care Plan, dated 2/7/2024, indicated the resident preferred the comfort of her room to that of attending group activities. She tended to refuse groups when invited. She liked to watch TV, have family visits and work word puzzles. She was a florists. Goal: the resident will be active with activity of choice in her room daily i.e.: TV, reading, talking on the phone. Attend a group out on the unit…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-06 · 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 secure a resident's cigarettes at the Nurse's Station for 1 of 1 resident who was reviewed for smoking. (Resident 11) Finding includes: During an observation on 4/29/24 at 11:37 A.M., Resident 11 had a long silver tray with an ashtray containing ashes, two cigarette butts, two cigarettes and a pack of opened cigarettes on a table in his room. Resident 11 had an empty ashtray sitting on his bedside table. Resident 11's record review was completed on 5/1/24 2:33 P.M. His diagnoses included, but were not limited to: cerebral infarction, hemiplegia following cerebral infarct, generalized anxiety, chronic atrial fibril, edema, anemia, chronic pain, arthritis, vascular dementia, type 2 diabetes. A Quarterly MDS (Minimum Data Set) assessment, dated 4/2/2024, indicated Resident 11 had intact cognition. A Care Plan, dated 2/8/2024, indicated Resident 11 had alteration in behavior as evidence by selling cigarettes to Assisted Living Residents. Interventions included, but were not limited to: if resident continued 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-06 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and observation, the facility failed to prevent a resident with dementia from wandering into other residents' rooms for 1 of 3 residents reviewed for dementia care. (Resident 53) Finding includes: During an interview on 4/30/2024 at 10:05 A.M., Resident 49 indicated Resident 53 came into his room often and sometimes she would take his belongings. He always got his belongings back. During an interview on 4/30/2024 at 2:30 P.M., Resident 40 indicated Resident 53 was confused and came into her room and took her things. Staff knew and kept the door closed, but Resident 53 still entered. Resident 40 indicated she always got her belongings back, but felt it frustrating to have the other resident in her room sometimes. Resident 53's record review was completed on 5/1/2024 at 9:16 A.M. Her diagnoses included, but were not limited to: dementia, Alzheimer's Disease and heart disease. A Quarterly Minimum Data Set (MDS) assessment, dated 2/6/2024, indicated Resident 11 had severe cognitive…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-06 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure shift narcotic counts sheets were completed and documented every shift for 1 of 2 narcotic books observed. (West Hall) Finding includes: During a medication storage observation on 5/3/2024 at 1:26 P.M. with RN 11, the narcotic sheets, dated 1/12/2024 to 4/8/2024, indicated not all shifts had all signatures to indicate the narcotics were counted every shift. There were 7 missing signatures for the day shift and 26 missing signatures for the evening and the night shifts. During an interview on 5/3/2024 at 1:27 P.M., RN 11 indicated the narcotics should be counted every shift and documented on the sheet. On 5/3/2024 at 1:47 P.M., the Director of Nursing provided the policy titled, Controlled Substance Administration and Accountability Policy, dated 4/8/2023, and indicated the policy was the one currently being used by the facility. The policy indicated . 2. Storage and Security: .b. Areas without automated dispensing systems utilize substantially-constructed storage unit with two locks and paper system…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-06 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure a resident who received an opioid and an anti-anxiety medication had an appropriate indication and was monitored for adverse side effects, for 1 of 5 residents whose medications were reviewed. (Resident 7) Finding includes: During an observation on 4/29/2024 at 12:27 P.M., Resident 7 was observed sitting in her wheelchair in the dining area yelling hey hey, and scratching her back on the wheelchair back. The resident, while being fed, was observed trying to scratch her back against the back of the wheelchair. During an observation on 4/30/2024 at 9:27 A.M., Resident 7 was observed sleeping in her wheelchair in the lounge area. During an observation on 5/2/2024 at 2:20 P.M., Resident 7 was observed sleeping in her wheelchair in the lounge area. During an observation on 5/2/2024 at 2:26 P.M., Resident 7's back had no red or open areas. A record review was completed on 5/2/2024 at 2:30 P.M. Resident 7's diagnoses included, but were not limited to, dementia, depression, anxiety and osteoarthritis. Current Physician…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-06 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure expired medications were removed from the medication cart and failed to monitor a medication refrigerator's temperature to prevent a large build up of ice in 1 of 1 medication cart and 1 of 1 medication rooms observed. (West Medication Cart & East Medication Room) Findings include: 1. On 5/3/2024 at 1:26 P.M. with RN 11 a medication storage observation was completed on the [NAME] medication cart. The following was observed: an opened bottle of lactulose liquid that had expired on 1/9/2024, and two opened bottles of Guafenesin syrup with expiration dates of 2/22/2024 and 3/2024. During an interview on 5/3/2024 at 1:35 P.M., RN 11 indicated the medications should have been removed from the cart. 2. During a medication storage observation on 5/3/2024 at 1:39 P.M. with RN 10, the following was observed on the East unit: the medication refrigerator had a large build up of ice in the freezer section of the fridge. The February temperature log sheet indicated the temperature was not documented 1 time for 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure catheter orders and catheter care orders were in place for a resident with a catheter, and failed to ensure intake and output were consistently documented as ordered, for 1 of 2 residents reviewed for catheters. (Resident B). Finding includes: On 2/12/24 at 10:12 A.M., Resident B's clinical records were reviewed. Diagnoses included, but were not limited to, stroke, peripheral vascular disease, epilepsy, and chronic pain syndrome. Resident B's most recent Minimum Data Set (MDS) assessment, dated 2/3/24, indicated the resident had severe cognitive impairment, rarely made himself understood, and only sometimes understood others. The resident had functional limitation impairment to upper and lower extremities on both sides, and was dependent on others for all Activities of Daily Living. Resident B had an indwelling catheter for urinary retention and failed voiding trials. Resident B was in Hospice care. On 1/6/23 at 9:26 A.M., Resident B was transferred to a local emergency room (ER) for chief complaint 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-04-04 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
    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, record review and interview, the facility failed to ensure the cook followed the recipes for pureed chicken. This deficient practice had the potential to affect 6 of 6 residents who required pureed food. (Cook 24) Finding includes: During an observation of the pureed food process, conducted on 3/28/23 at 9:29 A.M., [NAME] 24 placed 10 - 4 ounce scoops of diced cooked chicken into the food processor and added approximately 2 cups of water. After pureeing the mixture, she added two additional cups of water. Review of the recipe for pureed chicken indicated the chicken was to be pureed with chicken broth. During an interview with [NAME] 24 on 3/28/2023 at 9:40 A.M., she indicated the diced chicken had just been cooked in plain water and she had not added any flavoring nor followed the recipe using broth. Review of the facility policy and procedure, titled, Puree Food Prep Policy provided by the Director of Nursing on 3/30/2023 at 8:30 A.M., indicated: . It is the policy of this facility to provide puree food that has been prepared in a manner to conserve nutritive…

    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 · Fcited before2023-04-04 · 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 food was stored in accordance with professional standards for food safety for 1 of 1 kitchens. This deficient practice had the potential to affect 74 of 74 residents who received food from the kitchen. (Main Kitchen) Findings include: 1. During a tour of the kitchen, conducted on 3/27/23 at 9:44 A.M., with the senior FSS (Food Service Supervisor), the following was observed: There were 4 cases of unpasteurized eggs in the walk in refrigerator. The FSS indicated the eggs were supposed to be pasteurized and were ordered in error as the facility did serve fried eggs to residents.-The FSS immediately discarded the unpasteurized eggs and no under cooked, unpasteurized egg was observed being served during the survey process. During a review of Infection Surveillance, completed with the ADON, on 3/29/2023 at 11:00 A.M., there were no gastrointestinal outbreaks noted in the past year. One of two drainage pipes, located underneath an ice machine,was touching the side of the floor drain and no air gap 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-04-04 · tag F0585 — failed to handle grievances — pattern
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure information on how to file a grievance was made available to residents and contact information of the grievance official was posted prominently. In addition, 6 of 6 alert and oriented resident attending the Resident Council meeting did not know how to access a grievance form. (Residents 19, 44, 48, 49, 61 and 67) Findings include: 1. During the Resident council meeting on 3/27/23 at 11:21 A.M., 6 of 6 alert and oriented residents indicated they did not know how to access a grievance form if they desired to submit a grievance. Two of the 6 residents indicated they were not aware of the facility's grievance policy. 2. During an observation of the facility, on 3/29/2023 from 9:15 A.M. - 9:30 A.M., there were Resident Rights posters on the walls in the resident lounge area of every unit, but no specific information regarding the facility's grievance officer's contact information and no grievance forms available. During an interview with CNA 6, on 3/29/2023 at 9:17 A.M., she indicated there were probably…

    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 · Ecited before2023-04-04 · 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 over the counter medications were accurately labeled for 3 of 3 medication rooms observed and 2 of 3 medication carts observed. (East, Center and Grove unit medication rooms and East and Grove unit medicaiton carts) Findings include: During an observation of medication rooms and medication carts, conducted on 3/29/2023 at 10:09 A.M., the following was noted: 1. The Center unit medication room had a bottle of over- the- counter probiotic capsules with the date opened and the resident's name handwritten on the bottle. There was no physician's name and/or dose ordered written on the bottle. In addition, in the refrigerator, there was a bottle of liquid medication, labeled Omega D with only the resident's name written on the top of the bottle cap. During an interview RN 12 indicated only the resident's name and date opened had been written on the medications. 2. The East unit medication room had two partially used tubes of arthritic cream. There was no name or label on the medicated cream. 3. The East unit…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-04 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure the physician was notified of significant weight loss for 2 of 2 residents reviewed for nutrition. (Resident D & 7) and resident refusal to wear preventative equipment . (Resident D) Findings include: 1. The record for Resident 7 was reviewed on 3/30/2023 at 10:00 A.M. The diagnoses included but were not limited to: dementia with behavioral disturbances, anxiety disorder, and major depressive disorder. A Dietary Progress Note, dated 3/15/2023, indicated that she had a significant weight loss of 7.7% in 30 days and 10.5% in 180 days. A Care Plan, dated 4/18/2022, indicated to notify the physician and family if weight varies 5% in 30 days or 10% in 180 days. 2. A record for Resident D was on 3/29/2023 at 10:05 A.M. Diagnoses include, but were not limited to: edema, dementia with behavioral disturbances and history of bariatric surgery. A Dietary Progress Note, dated 2/15/2023, indicated that she had a significant weight loss of 8.9% at 90 days and 10.8% at 180 days. During an interview, on 3/31/2023 at 10:17 A.M., the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-04 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to develop and implement a personalized care plan for 2 of 24 residents whose care plans were reviewed. (Resident 8, 65) Findings include: 1. The record review for Resident 8 was reviewed on 3/29/2023 at 3:16 P.M. Diagnoses included, but were not limited to: anoxic brain damage, pulmonary emphysema and type 2 diabetes. During an observation, on 3/38/2023 at 12:15 P.M., there was a dressing dated 3/28/23 to Resident 8's right elbow. During an observation, on 3/29/2023 at 2:36 P.M., there was a dressing dated 3/29/23 to the right elbow. A Physician Order, dated 3/29/2023, indicated to clean the skin tear to the right elbow and cover with xeroform and dry dressing daily. During an interview, on 3/30/2023 at 11:33 A.M., the Assistant Director of Nursing (ADON) indicated that there was no care plan for a skin tear to the right elbow and there should have been one. 2. A record review for Resident 65 was completed on 3/29/2023 at 8:57 A.M. Diagnoses included, but were not limited to: Alzheimer's disease, atrial…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-04 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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

    Based on observation, interview and record review, the facility to update the plan of care for 4 of 17 residents reviewed for care planning. (Resident 8, 9, 65, D). Findings include: 1. The record for Resident 8 was reviewed on 3/29/2023 at 3:16 P.M. Diagnoses included, but were not limited to: anoxic brain damage, pulmonary emphysema and type 2 diabetes. A Quarterly Minimum Data Set (MDS) Assessment, dated 2/9/2023, indicated Resident 8 had one stage 2 and two stage 1 pressure ulcers. A Care Plan, dated 10/31/2022, indicated Resident 8 had a Kennedy ulcer to her coccyx and 2 unstageable pressure ulcers to her right foot. During an observation of wound care and skin inspection with the Wound Nurse, on 3/30/2023 at 10:25 A.M., no Kennedy ulcer was observed on the coccyx and the skin was intact with no discoloration. One unstageable ulcer was observed to the right inner heel. During an interview, on 3/30/3023 at 11:35 A.M., the Assistant Director of Nursing (ADON) indicated that the care plan should have been revised since the Kennedy ulcer and one of the unstageable ulcers 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-04 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to provide meaningful, personalized activities for 1 of 2 residents reviewed for activities. (Resident 65) Finding includes: During an observation on 3/27/2023 at 9:45 A.M. and 2:05 P.M., Resident 65 was observed lying in bed with no music or television playing in the room. During an observation on 3/28/2023 at 8:44 A.M., Resident 65 was in bed sleeping. During an observation on 3/29/2023 at 9:05 A.M., Resident 65 was in bed with no music or television on in the room. During an observation on 3/30/2023 at 10:14 A.M. and 2:38 P.M., Resident 65 was in bed with no music or television on in the room. A record review was completed on 3/29/2023 at 8:57 A.M. Diagnoses included, but were not limited to: Alzheimer's disease, atrial fibrillation, and diabetes mellitus type 2. A Significant Change Minimum Data Set (MDS) Assessment on 2/13/2023, indicated Resident 65 had severe cognitive impairment. The assessment indicated it was somewhat important to have books and magazines, to participate in religious activities, to do…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-04 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to transcribe orders timely, obtain an order for a completed treatment and document new skin issues. (Resident 41, 7, 8 ) Findings include: 1. A record review for Resident 41 was completed on 3/29/2023 at 1:30 P.M. Diagnoses included, but were not limited to: hemiplegia cerebral infarction right side, aphasia, and quadriplegia. An Annual Minimum Data Set (MDS) Assessment, dated 2/22/2023, indicated he was total dependent for bed mobility, transfers, toileting and personal hygiene with assist of 2 staff members. During an observation, on 3/27/2023, at 12:42 P.M., Resident 41 was up in a Broda chair, he had a carrot in his left hand, and splints to his feet/ankles only. During an observation, on 3/28 2023, at 9:11 A.M., the resident was in bed had no hand splints, prevalon boots or any leg devices in place and his heels were not floated. During an observation, on 3/28/2023 at 2:23 P.M., the resident was sitting in his room in a Broda chair. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-04 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to prevent an open area for 1 out of 4 residents reviewed for pressure ulcer/injury. (Resident 8) Finding Includes: The record for Resident 8 was reviewed on 3/29/2023 at 3:16 P.M. Diagnoses included, but were not limited to: anoxic brain damage, pulmonary emphysema and type 2 diabetes. A Quarterly Minimum Data Set (MDS) Assessment, dated 2/9/2023, indicated she was extensive assist of 2 staff for bed mobility, transfers, toileting, and personal hygiene and was at risk for pressure ulcer development. A Physician Order, dated 2/21/2023, indicated for the nurse to verify prevalon boots are on bilateral feet to off load pressure every shift. During an observation of a dressing change on 3/30/2023 at 10:44 A.M., the Wound Nurse lifted the sheet, the prevalon boots were twisted off the heels with the straps across the top of the foot/ankle. Two open areas were noted to the left anterior ankle distal measured 2.1 x 2.4 cm (centimeter) x 0.1 cm, and left anterior ankle proximal 0.5 x 1.5 x < 0.1 cm. The Wound Nurse…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure an intervention was implemented after a fall for 1 of 3 residents reviewed for accidents. (Resident 9) Finding includes: 1. The record for Resident 9 was reviewed on 3/30/2023 at 8:30 A.M. Diagnoses included, but were not limited to: history of falling, fracture of right radial closed fracture, and low back pain. A Significant Change, Minimum Data Set (MDS) Assessment, dated 12/20/2022, indicated the resident had a major injury from a fall. A Progress Note, dated 12/16/2022, indicated she got up out of the wheelchair and walked towards her room and fell, breaking her fall with her right hand. She complained of pain to the right wrist and an x-ray was ordered. She had a fracture of the right distal radius. A Care Plan for falls, dated 9/13/2022, indicated an intervention for the 12/16/2022 fall was to obtain an x-ray of the right wrist and notify the doctor of the results. During an interview, on 3/30/2023 at 9:31 A.M., the Director of Nursing indicated that they review the falls in the morning clinical meeting and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“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. 1 Medicare payment denial on record.

  • Medicare payment denial — starting 2024-08-02 for 7 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to GREENCROFT COMMUNITIES — 5 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 52.6+1.4 vs chain
Health inspection 3 of 52.0+1.0 vs chain
Staffing 4 of 53.6+0.4 vs chain
Quality measures 5 of 54.6+0.4 vs chain
The other 4 homes this chain runs (chain average 2.6★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
WOODLAWN HOSPITALOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 11/01/2015
BODE, GLENIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 12/09/2022
CHUDZYNSKI, KENDRAIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 10/15/2024
FISHER, ALANIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 06/13/2022
HEYDE, ALISONIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 09/01/2019
JOHNSON, TERRIIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 06/13/2022
MELLINGER, GREGORYIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 06/13/2022
MILLER, BRANDONIndividualMANAGING CONTROL - GOVERNING BODYsince 04/07/2025
WEBB, HARRYIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 10/15/2023
HAVEN HUBBARD HOMES, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2015
BALTES, CHRISTOPHERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/07/2019
DAVIS, HUGHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/08/2024
HOOTON, ROANNAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
KAUFFMAN, MARCYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023
LOW, BARBARAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2022
MCCLURE, CATHERINEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/14/2025
OLINSKI, LYNDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/08/2020
SWOPE, CAROLIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2016
WILLIAMSON, JEREMYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023

CMS files one row per role, so the 38 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$11.2M
Net patient revenuemost recent cost report
+3.5%
Operating marginrevenue minus expenses
$964K
Related-party expense9% of expenses
Who pays — share of resident-days
Medicaid 56%Medicare 3%Other / private 41%

This home reported $964K 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

$287per resident / day
operating cost
$8,736per month
≈ monthly operating cost
$298per 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 155672. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-08, 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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