Riverwalk Village
295 Westfield Rd, Noblesville, IN 46060 · Non profit - Corporation · 169 certified beds · (317) 773-3760 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0565)
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 3.7% | 11.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.5% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.4% | 1.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 21.6% | 25.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.1% | 3.9% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 6.9% | 11.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 21.4% | 23.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.0% | 3.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 24.9% | 23.3% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.1% | 13.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.7% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 96.1% | 79.0% | 79.4% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.45 | 1.61 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.48 | 1.44 | 1.80 | better |
‡ 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.
43.9% 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 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 33.3% 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 21 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.17 therapist hours per resident per day in 2026Q1 — more than 16% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 43.9%CMS range 30.9–56.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.7%CMS range 6.1–14.0 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 33.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 33.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 38.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not 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 discharge | not 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 stay | 3.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not 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 SNFs | 1.36 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 169 beds and averages 126.3 residents a day — about 75% occupied, or roughly 43 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.18 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.94 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.86 hrs/resident/day on weekends vs 3.31 on weekdays — 14% thinner on weekends. RN hours go from 0.39 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · D2026-01-20 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
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 residents were free from chemical restraints regarding the use of antipsychotic medication without gradual dose reductions and/or documented behavioral indicators for use for 2 of 4 residents reviewed for the use of antipsychotic medications (Resident 19 and 13). Findings include: 1. Resident 19's clinical record was reviewed on 1/15/26 at 10:25 a.m. Current diagnoses included dementia severe with agitation, anxiety and bipolar disorder.The resident had a current physician's order for the following antipsychotic medication: Risperdal 1mg- give 1 tablet two (2) times daily. This order originated 11/25/24 (1 year and 2 months).A 12/22/25, quarterly, Minimum Date Set (MDS) assessment indicated the resident was moderately cognitively impaired, did not have either hallucinations or delusions during the assessment period, did not display maladaptive behaviors during the assessment period, and received antipsychotic and antidepressant medications.The resident's clinical record contained documentation of three…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 immediate fall interventions and/or follow fall interventions to prevent further falls for a dependent resident at high risk for falls for 1 of 5 residents reviewed for accidents. (Resident 112)Finding includes:During an observation on 1/14/26 at 2:03 p.m., Resident 112 was seated in her wheelchair at the table in the dining room and being assisted with her meal. Resident 112's clinical record was reviewed on 1/14/26 at 3:16 p.m. Diagnoses included Alzheimer's Disease, atrial fibrillation, abnormal posture, unsteadiness on feet, and other abnormalities of gait and mobility. Current orders included metoprolol tartrate (blood pressure/heart rate) 25 mg every 12 hours (8/26/25).A 10/17/25, annual, Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired. A wheelchair was used for mobility. The resident was dependent on staff assistance for eating toileting, bathing, dressing, footwear, and personal hygiene. She required substantial staff assistance to stand 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.
- Potential for harm · Dcited before2025-11-19 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, recorded review, and interview, the facility failed to ensure residents were assessed for and deemed appropriate to self-administer medications for 1 out of 3 residents reviewed for medication administration. (Resident J) Findings include:During an interview and observation on 11/17/2025 at 10:28 a.m., Resident J indicated her morning medications had been given to her between 9:00 a.m. and 9:30 a.m. On the over-the- bed table, medication cup with several pills was observed. The resident indicated she had too many pills to take in the morning at one time.During an interview on 11/17/2025 at 10:31 a.m., LPN 6 indicated she had left the medication at the bedside during the morning medication administration pass. She indicated medications should not be left at the bedside. LPN 6 identified the medications in the medication cup as follows: amlodipine (calcium channel blocker) tablet 2.5 mg, ascorbic acid (vitamin C) tablet 500 mg, cyanocobalamin (vitamin B-12) tablet 1,000 mcg, fluoxetine capsule (anti-depressant) 40 mg, furosemide (diuretic) tablet 40 mg, losartan…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to accurately assess for fall risks, to implement fall interventions, and to thoroughly document falls for 1 of 3 residents reviewed for falls with injury. (Resident F) Findings include: Resident F's clinical record was reviewed on 11/26/24 at 4:00 p.m. Diagnoses included unspecified dementia, difficulty walking, and history of falling. A 8/29/24, Geriatric Interim Care Note from Resident F's admission paperwork indicated the following: fall one week ago on 8/21/24, with right hip pain ongoing. The fall one week ago was out of a chair onto right hip, did not hit head, able to get up unassisted. Hip was painful without improvement. He still walked and bore his own weight. Dementia with behavioral disturbances, likely mixed vascular and Alzheimer's Disease. He had been getting more assistance with ADLs and iADLs, which family had been providing. Skilled nursing placement required for wound care. A 9/3/24, admission Fall Assessment document indicated the resident had no falls in the previous six months, was incontinent of bowel…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-30 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure shift-to-shift narcotic count and reconciliation was completed for 6 of 7 medication carts reviewed for medication reconciliation. (Carts HI, [NAME], [NAME], C, D, and Cottage 2) Findings include: 1. During a medication storage observation of the HI medication cart, on 10/25/24 at 11:27 a.m., accompanied by LPN 7, the Narcotic Count Sheet was reviewed and the following dates lacked shift-to-shift count and reconciliation signatures of controlled medications: October 2024- lacked a narcotic card count: 1st, 2nd, 3rd, 4th, 5th, 6th, 7th, 8th, 9th, 10th, 11th, and 12th. October 2024- lacked shift-to-shift narcotic reconciliation signatures: 10/2: 6:00 a.m. - 2:00 p.m., 10/5: 6:00 a.m. - 2:00 p.m. and 2:00 p.m. - 10:00 p.m., 10/6: 6:00 a.m. - 2:00 p.m., 10/9: 6:00 a.m. - 2:00 p.m. and 2:00 p.m. - 10:00 p.m., 10/10: 6:00 a.m. - 2:00 p.m., 10/12: 6:00 a.m. - 2:00 p.m. and 10:00 p.m. - 6:00 a.m. 10/25: 6:00 a.m. - 2:00 p.m. During an interview, at the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-30 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
2. Resident 2's clinical record was reviewed on 10/25/24 at 9:30 a.m. Diagnosis included spastic quadriplegic cerebral palsy, unspecified severe protein-calorie malnutrition, oropharyngeal dysphagia, and epilepsy. A physician's order, dated 5/17/24, indicated may crush appropriate medications and administer per gastrostomy tube. Check placement of gastrostomy tube and check residuals (fluid or contents in the stomach). A physician's order, dated 6/4/24, indicated enteral feeding (to provide nutrition), gastrostomy tube, size 18 French (diameter of the tube). An isolation care plan, dated 6/10/24, indicated the resident was at risk of transferring Multidrug-Resistant Organisms (MDROs) and required enhanced barrier precautions related to indwelling medical devices. The approaches included to use standard precautions including hand hygiene and to wear gown and gloves for high-contact resident care activities. During an observation, on 10/23/24 at 9:50 a.m., Resident 2's room had an Enhanced Barrier Precautions sign on the wall directly beside the door. Personal protective equipment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-30 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to appropriately discard expired insulin pens and label medications with resident information in 2 of 6 medication carts observed for medication storage. (D and Cottage 2) Findings include: 1. During a medication storage observation of the D hall medication cart, accompanied by RN 3, on [DATE] at 12:15 p.m., the following was observed: One unlabeled 8 milligram (mg) ondansetron (to prevent vomiting) blister packaged pill. One glargine (insulin) pen, with approximately 25 units remaining, with an open date of [DATE]. During an interview, at the time of the observation, RN 3 indicated the ondansetron pill must have fallen out of the bag and the insulin was expired and should not be given to the resident. 2. During a medication storage observation of the Cottage 2 medication cart, accompanied by LPN 4, on [DATE] at 12:24 p.m., the following was observed: One unlabeled bottle of morphine (a narcotic pain reliever) with approximately 14 units remaining. During…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-04 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 complete verification of the correct type of insulin prior to administration for 1 of 3 residents reviewed for insulin use, resulting in the wrong type of insulin being given. (Resident B) Findings include: Resident B's clinical record was reviewed on 4/4/24 at 9:43 a.m. Diagnoses included type 2 diabetes mellitus without complications. His physicians orders included glargine-yfgn insulin (long-acting insulin) pen 40 units subcutaneously daily in the a.m. (started on 3/11/24) and Levemir (long- acting insulin) 55 units subcutaneously at bedtime (started on 2/20/24 - discontinued on 3/19/24). A 2/9/24 significant change Minimum Data Set (MDS) assessment indicated he was cognitively intact. His blood sugars on 3/16/24 were 180 mg/dL at 8:00 p.m., 184 mg/dL at 8:13 p.m., 150 mg/dL at 8:20 p.m., and 167 mg/dL at 8:33 p.m. A nurses note, dated 3/16/24 at 8:45 p.m. (recorded as a late entry on 3/17/24 at 3:09 p.m.), indicated a medication error was made. He received 55 units of Novolog insulin (short acting…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-04 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to date resident's insulin vials and insulin flex pens after opening in accordance with facility policy (Resident G, C, D, E, F, and H) for 2 of 3 medication carts observed. (H hall and K/I medication carts) During a medication administration observation, on 4/4/24 at 11:55 a.m., with RN 14, she administered 22 units of Lispro (short acting insulin) insulin to Resident G. Neither the insulin vial, nor the container, had an open date on it. RN 14 checked other in-use insulins stored in the H hall medication cart and the following in-use insulins lacked open dates: 1. Resident C's Lispro insulin vial. 2. Resident D's Lispro insulin vial and a glargine-yfgn (long acting insulin) insulin pen with 180 of 300 units used from the pen. 3. Resident E's insulin aspart (short acting insulin) insulin pen with 280 units of 300 units used from the pen. 4. Resident F's glargine-fygn insulin pen with 280 units of 300 units used from the pen. RN 12 indicated they would normally date the insulin vials and pens after opening.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-08 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 prevent the verbal and mental abuse of a severely cognitively impaired resident (Resident D) by a staff member (QMA 1). Using the reasonable person concept, it is likely this deficient practice would lead to chronic anxiety, or fear. Findings include: The clinical record of Resident D was reviewed on 3/6/24 at 12:18 p.m. Diagnoses included dementia with other behavioral disturbance, cognitive social or emotional deficit following cerebral infarction, depressive disorder, disorientation, and hypertension. The resident was living on the secured memory care unit. The most recent annual Minimum Data Set (MDS) assessment, dated 3/4/24, indicated the resident was severely cognitively impaired. Review of a facility self reportable, dated 3/1/24, indicated an allegation of verbal abuse was reported by staff. The reportable documented communication concerns between Resident D and QMA 1. Review of a written statement by Lab Tech 2, dated 3/1/24, indicated on 3/1/24 at 5:40 a.m., Resident D was standing up. The lab tech verbally…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · D2024-03-08 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based in record review and interview, the facility failed to ensure staff (QMA 1) reported suspicions of physical abuse of a severely cognitively impaired resident (Resident J) to the Administrator immediately per facility policy for 1 of 4 residents reviewed for abuse. Findings include: The clinical record for Resident J was reviewed on 3/8/24 at 11:27 a.m Diagnoses include dementia, epilepsy, and hypothyroidism. During an interview on 3/8/24 at 10:00 a.m., QMA 1 indicated on 3/1/24, during the night shift, while assisting with a lab draw, several staff members held Resident J down by force. QMA 1 indicated they did not report this incident to the Administrator per policy. During an interview on 3/8/24 at 10:33 a.m., the DON indicated the facility was not aware of the allegations until an unrelated interview was conducted with the QMA, approximately seven days after the incident. A current facility policy, dated 2/2010, titled Abuse Prohibition, Reporting, and Investigation was provided by the DON on 3/6/24 at 10:07 a.m. The policy indicated the following: Policy: It is the policy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-05 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to resolve resident grievances by providing adequate laundry services related to the accurate and timely return of personal resident clothing. (Resident C and Resident D) Findings include: 1. Review of a grievance form, dated 9/21/23, Resident C indicated missing personal items that included 1 black braided belt, 1 brown braided belt, missing teeth (dentures) costing $5000.00, and a $400.00 comforter. During an interview on 2/5/24 at 3:36 p.m., the DON indicated she had spoken to a family member of Resident C. The family had been able to find 1 missing belt. The teeth (bottom dentures) had been missing since 5/3/23. As of the survey, the missing comforter had not been found. The facility would start working with family to resolve the issue. 2. During an observation of a care conference on 2/2/24 at 1:31 p.m., Resident D and a family member verbalized the resident had been missing several personal clothing items for several months. After the care conference, the resident was allowed to go through the lost 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.
- Potential for harm · Dcited before2024-02-05 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to assess a resident (Resident B) after an unwitnessed fall, resulting in an delay of identification and treatment for a fracture of the left hip for 1 of 3 residents reviewed for change in condition. Findings include: The clinical record for Resident B was reviewed on 2/1/24 at 10:10 a.m. Diagnoses included chronic obstructive pulmonary disease, hypertension, atrial fibrillation, and weakness. The resident was admitted to the hospital and discharged from the facility on 1/25/24. The most recent quarterly Minimum Data Set (MDS) assessment, dated 12/5/24, indicated the resident required supervision and touch assistance for transfers and bed mobility. The resident used a wheelchair and walker for mobility. Review of a facility self-reportable, dated 1/25/24 at 3:43 p.m., indicated on 1/25/24 at 5:01 a.m., Resident B had an unwitnessed fall. Review of a Interdisciplinary Team progress note, dated 1/25/24 at 12:41 p.m., indicated a family member called the facility and stated the resident had fallen and had decrease movement on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-03 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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 meal service was completed in a sanitary manner for 3 of 3 residents reviewed for dietary services. (Residents H, J, and K) Findings include: The following was observed on 1/2/24 at 12:26 p.m.: LPN 4 picked up the top bun from Resident H's sandwich, in her ungloved hand, to place tartar sauce on top of the fish. LPN 4 replaced the bun and moved the plate in front of Resident H and returned to the cafeteria window to collect the next tray. LPN 4 picked up the top bun from Resident J's sandwich, in her ungloved hand, to place tartar sauce on top of the fish. LPN 4 replaced the bun on the plate in front of Resident J and returned to the cafeteria window to collect the next tray. LPN 4 picked up the top bun from Resident K's sandwich, in her ungloved hand, to place tartar sauce on top of the fish. LPN 4 replaced the bun on the plate in front of Resident K. 1. Resident H's clinical record was reviewed on 1/3/24 at 10:05 a.m. Diagnosis included type 2 diabetes mellitus, chronic viral hepatitis C, 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.
- Potential for harm · Dcited before2024-01-03 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 personal protective equipment (PPE) was worn during patient care for 1 of 3 residents with COVID-19 infection reviewed for infection control. (Resident E) Findings include: During an observation and interview, on 1/2/24 at 11:57 a.m., the Resident E's door was open and NA 1 was bent over, assisting the resident. NA 1 did not have on a gown, gloves, or face shield. Upon exiting the room, NA 1 indicated the droplet isolation sign located on outside the resident's room instructed what PPE she should have worn before entering the room to assist this resident. Resident E's clinical record was reviewed on 1/3/24 at 10:45 a.m. Diagnosis included chronic obstructive pulmonary disease (COPD), morbid obesity, and COVID-19. Current physician orders, dated 12/28/23 at 11:48 a.m., indicated, due to having an active infection with highly transmissible pathogens, this resident required droplet isolation related to signs and symptoms of COVID-19. During a follow up interview, on 1/3/24 at 11:58 a.m., the DON indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-10 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to resolve resident council concerns related to long call light wait times and missing clothing items. (Residents 5, 47, 4, 87, 59) Findings include: 1. During the Resident Council meeting on 10/4/23 at 11:00 a.m., residents present indicated there were long call light wait times, especially on second shift, and the wait was approximately an hour. There were times when staff members would wear ear buds/headphones while on duty, or turn off the call light without completing care, and this caused continued waiting. Resident 5 indicated during an incident last week, he was left on the toilet for 40 minutes. He could see the clock from the bathroom, since the door was left open. The J Hall staff assigned to his room on H hall were unable to see his call light past the large fire doors. Resident 47 indicated during an incident last week, she was left in a wet brief for approximately one hour. She could see the clock from her bed. Resident 4 indicated during an incident last week, she was left sitting on her bedside commode 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.
- Potential for harm · E2023-10-10 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
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 provide notice of transfer/discharge to a representative of the Office of the State Long-Term Care Ombudsman for 4 of 4 residents reviewed for hospitalization. (Residents 92, 22, 77, and 27) Findings include: 1. The clinical record for Resident 92 was reviewed on 10/3/23 at 3:02 p.m., Diagnoses included chronic respiratory failure, uropathy, chronic pain and abnormal weight loss. The resident was transferred to the hospital on 8/8/23 and returned to the facility on 8/11/23. The clinical record lacked documentation of the Ombudsman notification for the transfer/discharge. 2. Resident 22's clinical record was reviewed on 10/3/23 at 3:58 p.m. Diagnoses included obstructive and reflux uropathy and personal history of urinary tract infections. The resident was transferred to the hospital on 8/29/23 and returned to the facility on 9/2/23. The clinical record lacked an Ombudsman notification for a transfer/discharge on the above mentioned date. 3. 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.
- Potential for harm · D2023-10-10 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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, observation, and record review, the facility failed to ensure prompt wound care was provided in a manner to promote resident dignity for 1 of 1 residents reviewed for dignity. (Resident 5) Findings include: During an interview on 10/6/23 at 11:37 a.m., Resident 5 indicated when the wound physician came to evaluate his bilateral leg wounds, he would be asked to sit on the edge of the bed, since that position made it easier for the physician to view his bilateral lower extremities. The physician would remove his dressings, take measurements, and advise him a facility nurse would be in shortly to apply new, clean dressings. There were times where he waited 2 to 3 hours, sitting on the edge of the bed, before the nurse had time to do to his dressings. His wounds were open and stung when left uncovered. He was uncomfortable, but unable to climb back into bed as the open wounds were weeping and bloody, which made a mess of his bedding and his clothing. The contractures in his legs prevented other positions from being manageable for the wound dressing treatments or the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-10 · tag F0641 — isolatedEnsure 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 the Minimum Data Set (MDS) assessments were complete and accurate for 1 of 3 residents reviewed for oxygen therapy. (Resident 41) Finding includes: Resident 41's clinical record was reviewed on 10/3/23 at 3:26 p.m. Diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure with hypercapnia, obstructive sleep apnea, and dependence on supplemental oxygen. A current order, dated 9/21/23, indicated the resident required oxygen at two liters per minute via nasal cannula. A current order, dated 5/9/23, indicated the resident required Bi-level Positive Airway Pressure (BiPAP) every shift. A significant change Minimum Data Set (MDS) assessment, dated 8/27/23, lacked indication of specialized treatments for BiPAP and oxygen therapy. An Interdisciplinary Team Note, dated 8/23/23, indicated the resident was dependent on supplemental oxygen. During an interview on 10/4/23 at 3:18 p.m., the resident indicated she had worn continuous oxygen for at least 2 years. She had worn continuous…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-10 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure proper management of a supra-pubic urinary catheter and infection prevention strategies were utilized during catheter care for 1 of 5 residents reviewed for catheters. (Resident 85) Finding includes: During an interview on 10/2/23 at 3:35 p.m., Resident 85's representative indicated the resident had problems with sediment and crystallization that clogged his supra-pubic catheter on a frequent basis. The staff had not been flushing his catheter until about one week ago, when he got a urinary tract infection. There were times it had not been flushed for two to three days. They were not completing suprapubic catheter care every shift. He had been receiving pain medication to help with the supra-pubic pain. During the observation, the resident's urinary catheter tubing contained amber urine with moderate sediment. Resident 85's clinical record was reviewed on 10/3/23 at 4:27 p.m. Diagnoses included chronic kidney disease stage three, history of urinary tract infection, obstructive uropathy and benign…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to manage respiratory equipment and oxygen therapy as ordered for 2 of 3 residents reviewed for oxygen therapy. (Resident 41 and Resident 9) Findings include: 1. During an interview on 10/2/23 at 4:00 p.m., Resident 41 removed her BiPAP mask. She was receiving oxygen via nasal cannula, which was set on 4.5 liters per minute. The resident indicated she required continuous oxygen at five liters per minute. Her nebulizer tubing and canister were on her night stand, next to her bed. The tubing and canister were undated. The resident's nasal cannula tubing and humidity bottle was undated. She indicated the staff used to change the nasal cannula oxygen tubing, humidification, and nebulizer tubing on a regular basis, but they had not been done that in quite some time. The facility no longer changed the oxygen tubing on a routine basis, but instead, changed it when the residents complained because the tubing was hard. Resident 41's clinical record was reviewed on 10/3/23 at 3:26 p.m. Diagnoses included chronic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-10 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
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 the nursing staff were competent to demonstrate skills and techniques necessary to provide care for a resident with Huntington's disease for 1 of 30 residents reviewed during the survey. (Resident 38) Findings include: During an observation on 10/6/23 at 11:05 a.m., Resident 38 was seated at a table in the lounge area, in her wheelchair. A staff member was seated at the table and was assisting the resident to eat some chicken. The resident was observed with uncontrolled, quick movements with her arms and legs, and leaning movements with her upper body and head. The clinical record review for Resident 38 was completed on 10/4/23 at 11:43 a.m. Diagnoses included Huntington's disease, dementia, major depressive disorder, chronic pain syndrome, anxiety disorder, and psychotic disorder with delusions. A health care plan, dated 9/15/2023, indicated Resident 38 should be care in pairs for safety related to her involuntary movements due to her diagnoses of Huntington's disease. A goal included Resident 38…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-03 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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 — the official record, unedited, may be distressing
Based on observation, interview, and record review, the facility failed to ensure shower rooms were properly cleaned. This deficient practice had the potential to affect 19 of 19 residents who had the potential to receive care in the shower room. Findings include: During an observation of the H Hall shower room, on 8/2/23 at 1:40 p.m., accompanied by the Administrator and Maintenance Director, the following concerns were observed: a. A strong malodorous smell. b. Dried brown material on the floor and around the drain. This material was the source of the odor. The shower floors and walls were dry, indicating the shower room had not been used recently. c. Missing and broken tiles on the floor and near the drain. d. Dark black substance in the grout between tiles. During an interview at the time of the observation, the Administrator indicated the shower had not been cleaned and it would be addressed immediately. The broken and damaged tiles would also be addressed. The shower room should not have been left in that condition. This Federal Tag relates to complaint IN00413895. 3.1-19(f)(5)
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to AMERICAN SENIOR COMMUNITIES — 90 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.9 | +0.1 vs chain |
| Health inspection | 4 of 5 | 3.4 | +0.6 vs chain |
| Staffing | 1 of 5 | 2.3 | -1.3 vs chain |
| Quality measures | 5 of 5 | 4.7 | +0.3 vs chain |
The other 89 homes this chain runs (chain average 3.9★, per CMS)
Showing 40 of 89; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| DICE, MARK | Individual | CONTRACTED MANAGING EMPLOYEE | since 06/01/2023 |
| ROE, VICTORIA | Individual | CONTRACTED MANAGING EMPLOYEE | since 05/28/2024 |
| VAN CAMP, STEVEN | Individual | CONTRACTED MANAGING EMPLOYEE | since 09/06/2019 |
| WILLMAN, MARIA | Individual | CONTRACTED MANAGING EMPLOYEE | since 03/23/2024 |
| HORN, BRENDA | Individual | CORPORATE DIRECTOR | since 12/01/2023 |
| BABCOCK, PAUL | Individual | CORPORATE OFFICER | since 09/30/2020 |
| AMERICAN SENIOR COMMUNITIES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2003 |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.2M paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Indiana Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 155106. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-20, 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.