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Stonebrooke Rehabilitation Center

990 N 16th St, New Castle, IN 47362 · Government - County · 117 certified beds · (765) 529-0230 Medicare & Medicaid certified

Call the home — (765) 529-0230 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jun 2026Behavioral-health or dementia-care citations — no harm found (F0744, F0758)1 actual-harm citation
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2026
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)
  • about 25% 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 3 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1000 N 16th St Ste 250 · (765) 599-3555 · Call to confirm hours
Pharmacy
1000 N 16th St · (765) 521-1557 · Call to confirm hours
Grocery
1712 Broad St · (765) 529-7177 · Call to confirm hours
Park
116 N Main St · (800) 275-8777 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 1 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating 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 increased6.8%11.0%15.4%better
Long-stay residents who lose too much weight12.6%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection2.4%1.1%2.0%worse
Long-stay residents with depressive symptoms47.2%25.2%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury6.9%3.9%3.3%worse
Long-stay residents whose ability to walk worsened18.8%11.9%16.1%worse
Long-stay residents on antianxiety or hypnotic medication21.3%23.5%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.4%95.3%typical
Long-stay residents with pressure ulcers6.2%3.6%4.7%worse
Long-stay residents with worsening bladder/bowel control13.4%23.3%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table11.4%13.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.5%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine95.8%79.0%79.4%better
Short-stay residents rehospitalized after admission26.3%22.2%22.6%worse
Short-stay residents with an outpatient ER visit8.7%10.8%12.0%better
Long-stay hospitalizations per 1,000 resident days2.751.611.67worse
Long-stay outpatient ER visits per 1,000 resident days1.601.441.80better

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.

49.0% 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 58 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.0%U.S. median 51.5%
Got home and stayed home
11.7%U.S. median 10.7%
Went back to hospital
30.0%U.S. median 56.6%
Met the expected recovery
0.27U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 30.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 20 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 0.27 therapist hours per resident per day in 2026Q1 — more than 40% 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 SNF49.0%CMS range 37.1–60.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.7%CMS range 8.6–16.810.7%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 discharge30.0%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 discharge30.0%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 discharge35.0%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 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 worsened7.4%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 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 SNFs0.921.02Oct 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

0.50
RN hours/ resident / day
0.90
LPN hours/ resident / day
2.85
Aide hours/ resident / day
4.24
Total nurse hours/ resident / day
0.38
RN hoursweekends
38.8%
Total nursing turnover
57.1%
RN turnover

How full it usually is: this home is certified for 117 beds and averages 69.1 residents a day — about 59% occupied, or roughly 48 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 4.24 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.85 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.66 hrs/resident/day on weekends vs 4.48 on weekdays — 18% thinner on weekends. RN hours go from 0.55 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

5
deficiencies at the latest standard inspection (2025-05-20)
8
at the previous standard inspection (2024-03-22)

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.

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

  • Actual harm · Gcited beforedisputed · IDR2026-06-17 · 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 a resident was free from mental abuse by a staff member obtaining a photograph of the resident's genitalia without the resident's permission and showing other staff members resulting in unauthorized photographs taken for 1 of 4 residents reviewed for abuse. (Resident B) Using the reasonable person concept, it is likely this would lead to humiliation, confusion, anxiety, and embarrassment for Resident B. Findings include:The clinical record for Resident B was reviewed on 6/12/26 at 10:26 a.m. The diagnoses included, but were not limited to, morbid (severe) obesity, Alzheimer's disease (progressive, irreversible brain disorder that slowly destroys memory and thinking skills) with late onset, major depressive disorder, and anxiety. A physician's order, dated, 2/3/26, indicated Resident B had Dakin's Solution (a diluted hospital-grade bleach formula used as an antiseptic to cleanse wounds) with special instructions to cleanse scrotal abscess with NS (Normal Saline), pat dry, pack open area with Dakin's Solution, and…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-17 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to report an allegation of mental abuse of a resident by a staff member taking a picture of the resident's genitalia in a timely manner to the Indiana Department of Health (IDOH) for 1 of 4 residents reviewed for abuse. (Resident B) Finding include: The clinical record for Resident B was reviewed on 6/12/26 at 10:34 a.m. The diagnoses included, but were not limited to, muscle weakness, Alzheimer's disease (progressive, irreversible brain disorder that slowly destroys memory and thinking skills) with late onset, and anxiety. A facility reported incident, dated 2/8/26 at 8:55 a.m., indicated a staff member took unauthorized photo of resident. A phone interview with Certified Nursing Assistant (CNA) 2, dated 2/8/26 at 10:23 a.m., indicated she did take a picture of Resident B's wound earlier in the week of 2/2/26. CNA 2 indicated she was unsure what day she took the picture or what nurse she showed it to and was unsure if she had shown any other staff members as well. During an interview with Qualified Medical Assistant (QMA)…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-10-23 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide dignified incontinent care for 1 of 3 residents reviewed for dignity (Resident D). Finding include:During an interview with Resident D on 10/22/25 at 1:00 p.m., the resident indicated the facility staff treated her with dignity except CNA 3. CNA 3 was rough during incontinence care and it made her sore. The resident had told CNA 3 to go easy and he would say ok, but did not. CNA 3 was rushing with care and the resident felt it was disrespectful to her. Resident D indicated other than CNA 3 rushing, he was a good guy. The resident had reported this to a nurse and some of the other CNA's about Resident 3 being rough and rushing during care, but did not know their name. The staff have not fill out a grievance for her related to this matter. Review of the clinical record of Resident D on 10/23/25 at 11:31 a.m., indicated the resident's diagnoses included, but were not limited to, acute and chronic diastolic (congestive) heart failure, acute respiratory failure with hypoxia, Chronic obstructive pulmonary disease with…

    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 before2025-10-23 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to protect the residents' right to be free of verbal abuse for 2 of 4 residents reviewed for abuse. (Resident C and Resident F). Findings include:1. During an interview with Resident C on 10/22/25 at 1:05 p.m., they indicated Certified Nursing Assistant (CNA) 9 had come onto shift one morning to assist CNA 2 with incontinence care. Resident C indicated CNA 9 was upset with her upon entering the room and asked rudely, didn't they change you already?, and indicated she apologized for being wet and she couldn't control her bladder and CNA 9 kept saying hush it and using hand gestures for her to shut her mouth when she was trying to speak. The clinical record for Resident C was reviewed on 10/22/25 at 1:45 p.m. The diagnoses included, but were not limited to, lymphedema (swelling in the body's tissues due to blockage in the lymphatic system), hypertensive heart disease, and post-traumatic stress disorder. An admission Minimum Data Set (MDS) assessment, dated 9/25/25, indicated Resident C was cognitively intact, dependent with…

    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 · Dcited before2025-10-23 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to timely report an incident of alleged verbal abuse to the Executive Director for 1 of 1 resident reviewed for reporting abuse. (Resident C) Findings include:The clinical record for Resident C was reviewed on 10/22/25 at 1:45 p.m. The diagnoses included, but were not limited to, chronic pain syndrome, major depressive disorder, and hypertension.The annual Minimum Data Set (MDS) assessment, dated 9/25/25, indicated Resident C was cognitively intact.During an interview with Certified Nursing Assistant (CNA) 2 on 10/23/25 at 11:30 a.m., they indicated Resident C was upset and tearful on 10/15/25 after receiving incontinent care from CNA 9. CNA 2 indicated CNA 9 had hushed Resident C when she was apologizing for being wet, making hand gestures for her to shut her mouth and stop talking, and throwing dirty linens on the floor and saying in front of Resident C, great, now I'm covered in piss. CNA 2 indicated she wrote out a statement of the incident and placed it under every director's door the night of 10/15/25, so they received…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-20 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    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 showers as preferred for 2 of 3 residents reviewed for activities of daily living (ADLs). (Resident B and Resident E) Findings include: 1. During an interview with Resident E's daughter on 5/14/25 at 1:00 p.m., she indicated she did not think her mother was receiving her showers as regularly as she preferred. The clinical record for Resident E was reviewed on 5/16/25 at 9:42 a.m. The diagnoses included, but were not limited to, dementia, chronic kidney disease, repeated falls, and chronic pain syndrome. The admission Minimum Data Set (MDS) assessment, dated 4/17/25, indicated the resident was severely cognitively impaired for daily decision making. The resident was dependent on the staff for showering. The plan of care for Resident E, dated 4/4/25, indicated the resident required assistance with ADLs related to a mobility deficit, recent right hip fracture, and dementia. The interventions included, but were not limited to, assistance with bathing as needed per resident preference and to offer showers…

    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 before2025-05-20 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure a chair cushion was in place for a resident with stage 2 pressure ulcers (partial thickness skin loss) for 1 of 1 resident reviewed for pressure ulcers. (Resident E) Findings include: The clinical record for Resident E was reviewed on 5/16/25 at 9:42 a.m. The diagnoses included, but were not limited to, dementia, repeated falls, and chronic pain syndrome. During an observation on 5/14/25 at 1:25 p.m., Resident E had a chair cushion laying on the floor beside a chair. An interview with Resident E's daughter at that time indicated she had soiled the cushion the day before. So, the staff took the cover off for washing and put the cushion on the floor. During an observation on 5/15/25 at 10:26 a.m., Resident E was sitting in a wheelchair with no cushion in the seat. The cushion was lying on the floor beside a chair. The admission Minimum Data Set (MDS) assessment, dated 4/17/25, indicated Resident E was severely cognitively impaired, was at risk for pressure ulcers, and used a pressure reducing device for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-20 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident was weighed, as ordered, and a resident was provided with an adaptive drinking device, as ordered, for 2 of 6 residents reviewed for nutrition. (Resident 50 and Resident 59) Findings include: 1. The clinical record for Resident 59 was reviewed on 5/15/25 at 12:39 p.m. His diagnoses included, but were not limited to, hemiplegia and hemiparesis and malnutrition. He was admitted to the facility on [DATE]. The 5/6/25 ADL (activities of daily living) care plan indicated he required assistance with eating with an intervention to assist with eating and drinking, as needed. The vitals section of the clinical record indicated a weight of 100 pounds and a BMI (body mass index) of 16.64 (less than 18.5 was considered underweight) on 5/5/25. The 5/5/25 Malnutrition Criteria assessment indicated he met the criteria for malnutrition. The physician's orders indicated, Regular, Honey Thick/Moderately Thick, Pureed, Special Instructions:…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-20 · 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

    Based on observation, interview, and record review, the facility failed to implement interventions when residents were kissing in the common area on the memory care unit for 1 of 1 observation of behaviors (Resident 35 and Resident 53). Findings include: During an observation on 5/14/25 at 1:22 p.m., Resident 35 was sitting at a dining room table when Resident 53 bent down and kissed Resident 35 on the lips. This was reported to Registered Nurse (RN) 7. Certified Nurse Aide (CNA) 6 attempted to separate the residents and was unable to. Resident 35 and Resident 53 were holding hands, going up and down the hallway, and into their shared bedroom with the door shut unsupervised. CNA 6 indicated she attempted to separate them, but they were roommates and there was nothing she could do. CNA 6 indicated the residents were care planned for behaviors, but she was unsure what the interventions were. RN 7 was unsure what the interventions were and was looking them up on the computer. The Memory Care Coordinator indicated she had not seen this behavior of them kissing before and only previously…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-20 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure proper infection control measures were maintained during incontinence care for 1 of 1 resident observed for pressure ulcers. (Resident E) Findings include: The clinical record for Resident E was reviewed on 5/16/25 at 9:42 a.m. The diagnoses included, but were not limited to, dementia, repeated falls, and chronic pain syndrome. The admission Minimum Data Set (MDS) assessment, dated 4/17/25, indicated Resident E was severely cognitively impaired, was at risk for pressure ulcers, and was dependent on staff for toileting needs. During an observation of Resident E on 5/16/25 at 9:51 a.m., Certified Nurse Aide (CNA) 2 and CNA 3 entered Resident E's room to clean her up after being incontinent of bowel and bladder while lying in bed. CNA 2 and CNA 3 both donned gowns and gloves due to the resident being in Enhanced Barrier Precautions (EBP) due to wounds on the right and left buttock and labia. CNA 3 was cleaning Resident E's peri-area (area between the anus and the genitals) with a soapy wet washcloth. Each…

    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 · D2025-04-09 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to routinely document the meal intakes for 1 of 3 residents reviewed for resident assessment. (Resident B) Findings include: The clinical record of Resident B was reviewed on 4-9-25 at 10:55 a.m. Her diagnoses included, but were not limited to, vascular dementia, heart failure and moderate protein-calorie malnutrition. Her most recent Minimum Data Set (MDS) assessment, a significant change assessment, dated 2-18-25, indicated she was severely cognitively impaired, required supervision or touching assistance for meal consumption, had been identified for weight loss within the last six months, and received a therapeutic and mechanically altered diet. In an interview with Certified Nurse Aide (CNA) 4 on 4-9-25 at 12:35 p.m., she indicated Resident B had a big decline in eating and drinking abilities, prior to being sent out to an area hospital on 3-11-25. In an interview with the Assistant Director of Nursing (ADON) on 4-9-25 at 12:45 p.m., she indicated in the weeks prior to Resident B being sent out to an area hospital, 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 21 citations
  • Potential for harm · Fcited before2024-03-22 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure to maintain a clean, sanitary kitchen, ensure the holding refrigerator didn't contain unlabeled and/or expired foods, ensure bread was discarded that contained a fuzzy green, yellow substance, and ensure a cup was not present in the bulk storage bin. This had the potential to affect all 72 residents who receive food from the kitchen. Findings include: A kitchen tour was conducted on 3/18/24 at 10:45 a.m. with [NAME] 2. The holding fridge had a container of diced ham with a date of 3/6/24 and a use by date of 3/16/24. [NAME] 2 indicated she wasn't sure why they would make the use by date 10 days after the preparation date. The date was usually 7 days after the preparation date. There was prepared salad that contained cubed ham that did not have a date. There was a container of bacon bits underneath the cubed ham that was not dated. [NAME] 2 indicated she would add the label on the bacon bits due to them being prepared over the weekend. There were multiple boxes stored on the floor of the main freezer.…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-22 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure resident rooms were in good repair related to the walls, headboard, and cove base (soft flexible material along the bottom part of the wall) in a bathroom for 6 of 72 residents reviewed for environment. (Resident 283, 40, 18, 44, 11, and 28) Findings include: An observation conducted on 3/19/24 at 9:38 a.m. noted Resident 283's room with the cove base peeling in the bathroom. An observation conducted on 3/18/24 at 12:23 p.m. noted Resident 40's room with missing paint alongside the wall behind the headboard. An observation conducted on 3/18/24 at 12:34 p.m. noted Resident 18's room with missing paint and drywall behind the headboard. An observation conducted on 3/19/24 at 9:46 a.m. noted Resident 44's room with a flexible strip of material hanging down her headboard and onto her bed. She was lying in bed during the observation. An observation conducted on 3/19/24 at 1:07 p.m. noted Resident 11's room with missing paint alongside the wall behind the headboard. An observation conducted on 3/18/24 at…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-22 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to complete a Minimum Data Set (MDS) Assessment for a resident discharged from hospice services (Resident 78) for 1 of 3 resident reviewed for timeliness of significant change assessments. Findings include: The clinical record for Resident 78 was reviewed on 3/21/2024 at 1:45 p.m. The medical diagnosis included dementia. A payor census for Resident 78 indicated she discharged from hospice services on 10/12/2023. A physician note, dated 10/12/2023, indicated that Resident 78 was .hospice is releasing her soon . No significant change MDS Assessment was completed for Resident 78 in October of 2023. A policy entitled, Significant Change in Status Assessments (SCSA), was provided by the Administrator on 3/22/2024 at 10:00 a.m. The policy indicated, .SCSA is required to be performed when a terminally ill resident enrolls or revokes hospice program . An interview with the MDS Coordinator on 3/22/2024 at 11:15 a.m. indicated that she coded to the Resident Assessment Instrument Manual for accuracy and timeliness of assessments. She…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-22 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately indicate the use of hospice services (Resident 43) and failed to accurately code oxygen therapy (Resident 10 and 65) for 3 of 16 resident reviewed for MDS accuracy. Findings include: 1. The clinical record for Resident 43 was reviewed on 3/21/2024 at 2:30 p.m. The medical diagnosis included Alzheimer's disease with late onset. An Annual MDS Assessment for Resident 43, dated 2/18/2024, did not indicate the resident had a 6-month prognosis or received hospice services. A hospice certification, dated 1/30/2024, indicated that Resident 43 was terminally ill, elected the hospice benefit with a start of care date of 1/30/2024, and had a life expectancy of less than six months. An interview with MDS nurse on 3/21/2024 at 3:10 p.m., indicated that Resident 43 did not have a significant change completed due to not being sure when she was going to hospice because of the payor source confusion. 2. On 3/19/24 at 2:06 p.m., Resident 10 was observed lying…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-22 · 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 ensure continuation of treatment for a resident with pressure ulcers for Resident 55, and failed to ensure Resident 10 and 136's interventions were in place for pressure ulcer prevention and treatment. This affected 3 of 4 residents reviewed for pressure ulcers. Findings include: 1. The clinical record for Resident 55 was reviewed on 3/19/24 at 2:35 p.m. The diagnoses included, but were not limited to, cerebral infarction (or stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood), hemiplegia (total or nearly complete paralysis on one side of the body), dementia, glaucoma, and weakness. A pressure ulcer care plan, dated 1/3/24, indicated Resident 55 had pressure ulcers to the left and right heel, right hip, left intergluteal cleft, and left buttock. The approaches included, but were not limited to, treatments as ordered. A physician order, dated 3/5/24, indicated the utilization of Medihoney (sterile, hydrocolloidal dressing with 100% active Leptospermum honey that supports 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 · Dcited before2024-03-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure fall interventions were in place after a fall had occurred for 1 of 2 residents reviewed for accidents. (Resident 55) Findings include: The clinical record for Resident 55 was reviewed on 3/19/24 at 2:35 p.m. The diagnoses included, but were not limited to, cerebral infarction (or stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood), hemiplegia (total or nearly complete paralysis on one side of the body), dementia, glaucoma, and weakness. A care plan for fall risk, dated 4/6/23, indicated Resident 55 was at risk for falls due to history of falls, medication usage, incontinence, and weakness. The approach included, but were not limited to, a bedside mat while resting in bed that was started on 11/20/23. A fall event, dated 2/15/24 at 11:42 p.m., indicated Resident 55 fell out while sleeping and the Matt [sic] not at bedside. A progress note, dated 2/15/24 at 11:52 p.m., indicated the following, .This nurse alerted to resident's room per roommate yelling for help, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-22 · 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 and record review the facility failed to have an ongoing activity program on the dementia care unit for 2 of 3 residents reviewed for activities (Resident C and Resident D). Findings include: 1.) During an interview with CNA 3 on 3/20/24 at 11:58 a.m., indicated she normally worked the dementia care unit. CNA 3 indicated there was not enough activities on the dementia care unit until recently when an activity assistant started working. The dementia unit went a long time without activity staff. During an interview with the Dementia Care Coordinator on 3/20/24 at 12:21 p.m., indicated the facility had not had an activity assistant since June 2023. The Dementia Care Coordinator was working in three different roles on the dementia care unit, the Dementia Care Coordinator, Social Services and activities. The facility did hire someone the end of February 2024 for activities. The staff did the best they could with activities, providing self initiated packets and coloring. During an interview with CNA…

    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 before2024-03-22 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a dietary staff member did not work while experiencing signs and symptoms of a gastrointestinal illness and ensure 48 hours had passed since symptoms started. Findings include: A kitchen tour was conducted on 3/18/24 at 10:45 a.m. with [NAME] 2. [NAME] 2 indicated the Dietary Manager was out ill. An interview conducted with the Dietary Manager (DM), on 3/20/24 at 2:53 p.m., indicated that she was having symptoms of a gastrointestinal illness while at work on 3/18/24 and so she went home. She did return to work on 3/19/24 and was putting away the food shipment that came on Friday, 3/15/24. A policy titled Employee Illness, revised 12/2023, was provided by the Administrator on 3/21/24 at 3:30 p.m. The policy indicated the following, .Purpose of Policy: Resident(s) will not be exposed to employee(s) who show signs and symptoms of illness or infectious disease .Employees returning to duty after an infectious illness will consult the DNS [Director of Nursing Services], Infection Preventionist/designee before returning 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-26 · 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 interview and record review, the facility failed to ensure a resident identified with non-pressure-related skin concerns had timely and routine assessments and documentation of the same conducted of their skin concerns for 1 of 3 residents reviewed for skin issues. (Resident D) Findings include: The clinical record of Resident D was reviewed on 9-25-23 at 3:45 p.m. Her diagnoses included, but were not limited to a history of acute respiratory failure, COPD (chronic obstructive pulmonary/lung disease), diabetes, neuromuscular dysfunction of bladder, morbid obesity, high blood pressure, hyperlipidemia, depression, occlusion and stenosis of bilateral carotid arteries, IBS, fatty liver disease, weakness, anxiety, general muscle weakness, spinal stenosis of lumbar region, knee pain, unspecified osteoarthritis and nutritional anemia. Her most recent Minimum Data Set assessment, dated 5-18-23, indicated she was cognitively intact, had mood issues related to tiredness, depression and sleep, was dependent of 1 or more staff for activities of living, such as bed mobility, transfer,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-01-24 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure temperature logs were completed and the sanitizing solution was tested for a chemical dishwasher that resulted in lack of sanitizing solution being distributed for an unknown period of time. This had the potential to affect all 78 residents that receive food from the kitchen. Findings include: An observation of the kitchen was conducted on 1/18/23 at 10:30 a.m. Culinary Assistant (CA) 11 was proceeding to run dirty dishes through the dishwasher. CA 11 indicated the machine was a chemical dishwasher. The dial registered the temperature to be 138 degrees. She took a testing strip for the sanitizing solution and the strip did not change color to indicate the presence of a chemical sanitizing solution. CA 11 proceeded to press a button the prime the line to see if sanitizing solution was coming out and there wasn't any exiting the line. There was a bin located underneath the dishwasher to which CA 11 indicated was the sanitizing solution and it was low. This will occur when the sanitizing solution bin is…

    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 · E2023-01-24 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to maintain clean tables in the activity/dining room on the locked unit. This affected all 19 residents who used the activity/dining room. Findings include: On 1/20/23 at 2:03 p.m., the six square tables in the activity/dining area were observed to have a build up of a brown, gummy substance around all the edges. There were six square tables and one rectangle table. The rectangle table is wooden and the wooden legs were scuffed and marred. On 1/23/23 at 3:14 p.m., the dining room/activity room was observed to have six square tables and one rectangle table. The square tables have a metal stand in the center of the table to the floor with 4 supports that come out from the metal pole. The square tables have a laminated wood grain top with an off white band around the table edges. The band has streaks of a brown substance in the crease of the edge of the table, and scattered brown/tan smudges along the band. The rectangle table has scuffed and marred table legs on all 4 of the legs. The edge of the table has faded…

    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 before2023-01-24 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    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 accuracy of the MDS (Minimum Data Set) assessment regarding 2 residents' dental status (Resident 61 and Resident 47), indicate the use of BiPap/CPAP device for Resident 39, and indicate dialysis for Resident 43 for 4 of 29 residents reviewed for MDS accuracy. Findings include: 1. The clinical record for Resident 47 was reviewed on 1/23/23 at 10:43 a.m. The diagnoses included, but were not limited to, congestive heart failure, diabetes mellitus, vascular dementia, weakness, dysphagia, and malnutrition. A care plan for dental care, dated 2/8/22, indicated Resident 47 had caries or missing teeth. An admission MDS assessment, dated 2/17/22, indicated Resident 47 had none of the above in regard to dental concerns. A significant change MDS assessment, dated 3/22/22, indicated Resident 47 had none of the above in regard to dental concerns. Another significant change MDS assessment, dated 4/17/22, indicated Resident 47 had none of the above in regard to dental concerns. Another significant change MDS…

    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 · E2023-01-24 · 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 interview and record review, the facility failed to develop and implement care plans for a resident with high blood pressure medications and low thyroid hormone medication (Resident 36), a resident with a catheter (Resident 74), a resident with a BiPap (bilevel positive airway pressure)/CPAP (continuous positive airway pressure) for Resident 39, and low air loss mattress for Resident 50. This affected 4 of 29 reviewed for care plans. Findings include: 1. Resident 36's record was reviewed, on 1/20/23 at 1:53 p.m., and indicated diagnoses that included, but were not limited to, dementia, psychotic disorder with delusions, other sleep disorders, depression, anxiety, high blood pressure, cognitive communication deficit, and hypothyroidism (low thyroid hormone). An admission Minimum Data Set assessment, dated 12/11/22, indicated Resident 36 was severely impaired in cognitive skills for daily decision making, had behaviors directed toward others, wandering, had non-Alzheimer's dementia, anxiety 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-24 · 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 observation, interview, and record review, the facility failed to ensure showers were provided as preferred (Resident 31) and a resident was toileted timely that resulted in incontinence (Resident 46) for 2 of 3 residents reviewed for activities of daily living (ADLs). Findings include: 1. The clinical record for Resident 31 was reviewed on 1/20/23 at 2:18 p.m. The diagnoses included, but were not limited to, muscle weakness, anxiety disorder, and repeated falls. A quarterly minimum data set (MDS) assessment, dated 12/26/22, indicated Resident 31 was cognitively intact and assistance of 1 staff person for personal hygiene and bathing. An interview conducted with Resident 31, on 1/19/23 at 10:28 a.m., indicated she had not received a shower for 2 weeks and within the past week she had received a sponge shower. She prefers to have a shower. A care plan for ADLs, dated 4/7/22, indicated Resident 31 required assistance with ADLs and the approach to assist with bathing as needed per resident preference. Offer showers two times per week with a partial bath in between. A document…

    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 before2023-01-24 · 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 interview and record review, the facility failed to follow-up with a change in a resident's condition of decreased level of consciousness and decreased appetite that was later hospitalized with sepsis for 1 of 3 residents reviewed for change of condition. (Resident G) Findings include: The clinical record for Resident G was reviewed on 1/24/23 at 1:25 p.m. The diagnoses included, but were not limited to, weakness, chronic obstructive pulmonary disease, chronic kidney disease, muscle weakness, congestive heart failure, atrial fibrillation, diabetes mellitus, repeated falls, and mild cognitive impairment. A quarterly MDS (Minimum Data Set) assessment, dated 11/4/22, indicated he was cognitively intact and required extensive staff assistance with transfers, dressing, personal hygiene along with supervision for bed mobility and toilet use. He was occasionally incontinent of bladder and always continent of bowel. A care plan, dated 10/21/22 and discontinued on 1/17/22, indicated Resident G was at risk for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-24 · 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 ensure a treatment was initiated timely for an identified pressure ulcer after readmission to the facility for 1 of 3 residents reviewed for pressure ulcers. (Resident 47) Findings include: The clinical record for Resident 47 was reviewed on 1/23/23 at 3:10 p.m. The diagnoses included, but were not limited to, congestive heart failure, vascular dementia, malnutrition, and diabetes mellitus. A care plan for skin integrity, dated 12/21/22, indicated Resident 47 admitted with pressure ulcers to left buttock and right heel. An approach was listed for treatment as ordered. An admission observation, dated 1/4/23, indicated Resident 47 had an ulcer to the right buttock and left buttock that was open upon readmission to the facility. A document titled Wound Management Detail Report for Resident 47 indicated a wound assessment of the right buttock pressure ulcer was noted on 1/5/23 with measurements of 0.4 x 0.5 x 0.1 centimeters. A pressure ulcer was noted to the left buttock with measurements of 1.5 x 1 x 0.2 centimeters. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-24 · 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 implement fall interventions for a Resident at risk for falls for 1 of 3 residents review for fall management. (Resident 43) Findings include: The clinical record for Resident 43 was reviewed on 1/20/2023 at 11:40 a.m. The medical diagnoses included end stage renal disease and diabetes mellitus type two. A 5-day Minimum Data Set Assessment, dated 12/28/2022, indicated that Resident 43 was cognitively impaired and had one fall since prior assessment without injury. A care plan, dated 1/22/2021, indicated that Resident 43 was at risk for falls due to history of falling, incontinence, high risk medication, oxygen acting a tether, impaired cognition, impaired mobility, unsteady gait, multiple comorbidities, weakness, and amputation. A fall intervention, dated 11/21/2022, indicated to wrap call light with brightly colored tape. An observation on 1/19/2023 at 4:44 p.m. indicated Resident 43 was laying in bed at this time with his call light within reach, it was a standard off-white call light with no tape in place.…

    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 · D2023-01-24 · 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 interview, observation, and record review, the facility failed to promote Resident 234's dignity by utilizing a dignity bag with a urinary catheter drainage bag and failed to ensure Resident 74's urinary catheter drainage bag was kept free of contact with the floor for 2 of 3 residents reviewed for urinary catheter management. Findings include: 1. The clinical record for Resident 234 was reviewed on 1/19/2023 at 1:14 p.m. The medical diagnoses included muscle weakness and urinary tract infections. A 5-day Minimum Data Set Assessment, completed on 1/12/2023, indicated Resident 234 was cognitively intact, utilized an indwelling urinary catheter and needed extensive assistant with hygiene activities of daily living. A urinary catheter care plan, dated 1/10/2023, indicated the intervention of storing the urinary catheter collection bag inside a protective dignity pouch. An observation on 1/18/2023 at 4:30 p.m. indicated Resident 234 laying in bed with a urinary catheter drainage bag hanging from the left side of her bed with a moderate amount of yellow urine visible. An…

    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 · D2023-01-24 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a pharmacy recommendation was followed up timely by the physician, for 1 of 5 residents reviewed. (Resident 72) Findings include: Resident 72's record was reviewed on 1/20/23 at 11:49 a.m. The record indicated Resident 72 had diagnoses that included, but were not limited to, Alzheimer's disease with late onset, dementia, with behavioral disturbance, high blood pressure, cognitive communication deficit, visual hallucinations, depression, delirium, and wandering. An admission Minimum Data Set assessment (MDS), dated [DATE], indicated Resident 72 was severely impaired in cognitive skills for daily decision making, understands others and is understood by others, had no behaviors, had Alzheimer's disease, and non-Alzheimer's dementia, received antipsychotic medications for 7 of the 7 assessment days, and antidepressant medications for 6 of the 7 assessment day. Current physician's orders included, but were not limited to, fluoxetine (antidepressant)…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-24 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to provide education for the risk of using antipsychotic medications (Residents 36 and 72), and failed to identify and monitor target behaviors for a resident receiving antipsychotic medications (Resident 42). This affected 3 of 5 residents reviewed for unnecessary medications. Findings include: 1. Resident 36's record was reviewed, on 1/20/23 at 1:53 p.m., and indicated diagnoses that included, but were not limited to, dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, psychotic disorder with delusions, other sleep disorders, depression, anxiety, high blood pressure, cognitive communication deficit, and low thyroid hormone. An admission Minimum Data Set assessment, dated 12/11/22, indicated Resident 36 was severely impaired in cognitive skills for daily decision making, had behaviors directed toward others, wandering, had non-Alzheimer's dementia, anxiety and depression, received antipsychotic medication 7 of the 7 assessment days, and a gradual dose reduction was not…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-24 · tag F0825 — isolated
    Provide or get specialized rehabilitative services as required for a resident.
    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 therapy recommendations were followed through and therapy referrals were followed up with timely for 1 of 2 residents reviewed for therapy services. (Resident 62) Findings include: The clinical record for Resident 62 was reviewed on 1/19/23 at 1:46 p.m. The diagnoses included, but was not limited to, dysphagia, adult failure to thrive, and cognitive communication deficit. Resident 62 was admitted to the facility on [DATE]. An admission (MDS) Minimum Data Set assessment, dated 1/7/21, indicated no impairment in Resident 62's range of motion (ROM) to the upper and lower extremities. An Occupational Therapy (OT) Discharge summary, dated [DATE], indicated the following, .Discharge Plans & Instructions .Patient discharge to same SNF [skilled nursing facility] with 24 hour assistance as needed due to payor change. Recommendations for continuation of skilled therapy services under new payor in order to facilitate increased engagement and independence…

    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.

“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.

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 AMERICAN SENIOR COMMUNITIES — 90 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 53.9-0.9 vs chain
Health inspection 3 of 53.4-0.4 vs chain
Staffing 2 of 52.3-0.3 vs chain
Quality measures 2 of 54.7-2.7 vs chain
The other 89 homes this chain runs (chain average 3.9★, per CMS)
1 of 5Valparaiso Care & RehabilitationValparaiso, IN 2 of 5Arbor Grove VillageGreensburg, IN 2 of 5Bethany VillageIndianapolis, IN 2 of 5Columbia Healthcare CenterEvansville, IN 2 of 5Community Nursing And Rehabilitation CenterIndianapolis, IN 2 of 5Eagle Valley MeadowsIndianapolis, IN 2 of 5Harcourt Terrace Nursing And RehabilitationIndianapolis, IN 2 of 5Harrison TerraceIndianapolis, IN 2 of 5Hickory Creek At New CastleNew Castle, IN 2 of 5Maple Park VillageWestfield, IN 2 of 5Park Terrace VillageEvansville, IN 2 of 5Riverside VillageElkhart, IN 2 of 5Trailpoint VillageSouth Bend, IN 2 of 5University Nursing CenterUpland, IN 2 of 5Williamsport Nursing And RehabilitationWilliamsport, IN 3 of 5Allisonville MeadowsFishers, IN 3 of 5American VillageIndianapolis, IN 3 of 5Brownsburg MeadowsBrownsburg, IN 3 of 5Countryside MeadowsAvon, IN 3 of 5East Lake Nursing & Rehabilitation CenterElkhart, IN 3 of 5Hickory Creek At CrawfordsvilleCrawfordsville, IN 3 of 5Hillcrest VillageJeffersonville, IN 3 of 5North Capitol Nursing & Rehabilitation CenterIndianapolis, IN 3 of 5Rosebud VillageRichmond, IN 3 of 5Rosewalk VillageIndianapolis, IN 3 of 5Rosewalk Village At LafayetteLafayette, IN 3 of 5Spring Mill MeadowsIndianapolis, IN 4 of 5Autumn Ridge Rehabilitation CentreWabash, IN 4 of 5Beech Grove MeadowsBeech Grove, IN 4 of 5Clark Rehabilitation And Skilled Nursing CenterClarksville, IN 4 of 5Clinton GardensClinton, IN 4 of 5Creekside VillageMishawaka, IN 4 of 5Edgewater WoodsAnderson, IN 4 of 5Forest Creek VillageIndianapolis, IN 4 of 5Franklin MeadowsFranklin, IN 4 of 5Heritage House Rehabilitation & Health Care CenterConnersville, IN 4 of 5Hickory Creek At ColumbusColumbus, IN 4 of 5Hickory Creek At MadisonMadison, IN 4 of 5Hickory Creek At PeruPeru, IN 4 of 5Hickory Creek At RochesterRochester, IN

Showing 40 of 89; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleShareSince
HENRY COUNTY MEMORIAL HOSPITALOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 01/01/2023
CHIES, STEVENIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2023
DYNES, SHELDONIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 01/01/2013
JACKSON, BLAKEIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2023
JACKSON, ETHANIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2023
JACKSON, MARKIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2023
JACKSON, MICHAELIndividualMANAGING CONTROL - GOVERNING BODYsince 05/14/2024
JACKSON, WESSLEYIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2023
JUSTICE, DAVIDIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2023
KELSEY, DONNAIndividualMANAGING CONTROL - GOVERNING BODYsince 07/18/2024
PIDGEON, JOHNIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 01/01/2013
SHORE, MARIONIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 01/01/2013
STITLE, STEPHENIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2023
WARE, DEBORAHIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 08/27/2021
WRIGHT, THERESSAIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2023
RING, BRIANIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2023
AMERICAN SENIOR COMMUNITIES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023
CARTER, AMYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023
DAVIS, KEITHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/18/2025
DICE, MARKIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2023
RAINS, AMANDAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 11/28/2021
RENO, ASHLEYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2026
SHANE, ANDREWIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2023
VAN CAMP, STEVENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2023

CMS files one row per role, so the 36 rows in the source record cover these 24 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.

$9.0M
Net patient revenuemost recent cost report
-2.4%
Operating marginrevenue minus expenses
$2.3M
Related-party expense25% of expenses
Who pays — share of resident-days
Medicaid 78%Medicare 6%Other / private 16%

About 78% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.3M paid to related parties — landlords or management companies under common ownership — equal to about 25% 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

$350per resident / day
operating cost
$10,640per month
≈ monthly operating cost
$342per 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 155160. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-20, 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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