Peabody Retirement Community
400 W Seventh St, North Manchester, IN 46962 · Non profit - Corporation · 192 certified beds · (260) 982-8616 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Nov 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 1 actual-harm citation
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $22,071 in federal fines (most recent 2024-06-07)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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 | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 7.0% | 11.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.4% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 1.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 8.3% | 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 | 3.6% | 3.9% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 10.6% | 11.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 20.9% | 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 | 2.9% | 3.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 31.2% | 23.3% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.3% | 13.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 87.9% | 79.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 17.3% | 22.2% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 6.1% | 10.8% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.18 | 1.61 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.66 | 1.44 | 1.80 | typical |
‡ 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.
58.5% 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 83 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 48.9% 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 45 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 0.23 therapist hours per resident per day in 2026Q1 — more than 28% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | 58.5%CMS range 48.3–69.0 | 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 | 10.6%CMS range 7.8–14.2 | 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 | 48.9% | 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 | 48.9% | 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 | 42.2% | 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 | 98.5% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 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 | 2.9% | 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 | 6.8%CMS range 4.2–12.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.08 | 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 192 beds and averages 174.5 residents a day — about 91% occupied, or roughly 18 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.19 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.40 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.88 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 3.90 hrs/resident/day on weekends vs 4.30 on weekdays — 9% thinner on weekends. RN hours go from 0.43 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 54% 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.
26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.
- Immediate jeopardy · Jcited before2024-06-07 · 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, interview, and record review, the facility failed to ensure a resident who was cognitively impaired and assessed as an elopement risk, was observed overnight and provided with care checks. This deficient practice resulted in the resident eloping from the facility and being unaccounted for overnight for 1 of 3 residents reviewed for elopements. (Resident B) The Immediate Jeopardy began on 5/23/24 when the facility failed to ensure a resident who was cognitively impaired and assessed as an elopement risk, was observed overnight and provided with care checks. The resident eloped from the facility on 5/23/24 at 10:34 p.m. and being unaccounted for overnight until 5/24/24 at 7:09 a.m. when he was found in a local park approximately one-half mile from the facility. The resident complained of being cold and had been incontinent of bowel when he was located by a staff member. The Administrator was notified of the Immediate Jeopardy at 4:59 p.m. on 6/5/24. The Immediate Jeopardy was removed, and the deficient practice corrected on 5/24/24, prior to the start of 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.
- Actual harm · Gcited before2024-04-18 · tag F0744 — failed to care for residents with dementia — isolatedProvide 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 ensure services for effective supervision were provided to ensure a pencil sharpener was not left unattended and within the reach of a cognitively impaired resident with dementia for 1 of 3 residents reviewed for dementia care. This deficient practice resulted in Resident B ingesting the sharpener blade and required hospitalization for surgical removal. Findings include: On 4/16/24 at 11:10 a.m., Resident B was observed in A wheelchair at a table in the common area, with a staff member sitting next to her. On 4/18/24 at 12:07 p.m., Resident B was observed in a wheelchair with her head down and her eyes closed, in the dining room. A staff member was assisting another resident at the same table. Resident B's clinical record was reviewed on 4/16/24 at 10:47 a.m. Diagnoses included, but were not limited to, Alzheimer's disease with early onset, dementia in other disease classified elsewhere, moderate, with agitation, psychotic disorder with delusions due to known physiological condition, and unspecified mood…
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 before2026-06-30 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure hospital discharge orders were accurately transcribed to ensure continuation of treatment for 2 of 3 residents reviewed for new admissions. (Resident B and Resident D)Findings include:1.Resident B's clinical record was reviewed on 6/29/26 at 9:29 a.m. Diagnoses included essential (primary) hypertension, anxiety disorder, depression, and bipolar II disorder.A behavioral health care office note, dated 2/4/26, indicated Resident B's medications included bupropion (antidepressant) 200 milligram (mg) every morning and at noon, and divalproex (anticonvulsant/mood stabilizer) 500 mg in the morning and 1000 mg at bedtime. He was discharged from the hospital to the facility on 3/11/26. Discharge orders included bupropion 450 mg daily, divalproex sodium 500 mg daily, divalproex sodium 250 mg twice daily, and divalproex sodium 1000 mg at bedtime. The March 2026 Medication Administration Record (MAR) indicated divalproex sodium 500 mg at bedtime 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 · E2026-05-18 · tag F0644 — patternCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete a required Preadmission Screening and Record Review (PASRR) Level I screening assessment to determine if a Level II assessment was required when a resident received a new major mental illness diagnosis for 3 of 3 residents reviewed for PASRR (Resident 2, Resident 6, and Resident 160). Findings include: 1. Resident 160's clinical record was reviewed on 5/14/26 at 12:37 p.m. Diagnoses included psychotic disorder with delusions due to known physiological condition, depression, anxiety, and mood disorder due to known physiological condition with depressive features. Resident 160's clinical record indicated mood disorder was added as diagnosis 4/3/24 and the psychotic disorder diagnosis was added 4/1/25. A PASARR level I screening, dated 10/10/19, indicated Resident 160 had a diagnosis of depression/depressive disorder and took the medication escitalopram (antidepressant). The record lacked any additional Level I screenings. A physician's order,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-18 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to identify targeted behaviors and individualized interventions to clinically support the use of an antipsychotic medication for 2 of 2 residents reviewed for chemical restraints. (Residents 2 and 3) 1.During an observation on 5/12/26 at 10:02 a.m., Resident 2 was asleep in his wheelchair and the television was on. On 5/14/26 at 11:18 a.m., Resident 2 was sitting in his wheelchair in his room talking with a visitor. He laughed intermittently and waved to staff passing by. On 5/18/26 at 10:45 a.m., Resident 2 was up and dressed, sitting in his wheelchair in the living area, watching television. He was quiet and slept intermittently. Resident 2's clinical record was reviewed on 5/14/26 at 10:05 a.m. Diagnoses included senile degeneration of the brain (2/3/26), depression (9/8/23), unspecified dementia (unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety) (9/11/23), anxiety disorder…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-18 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure insulin pen needles were primed prior to administration according to manufacturer's instructions and professional standards to ensure the full dosage was received for 1 of 14 residents reviewed for medication administration. (Resident 17)Findings include:On 5/13/26 at 6:58 p.m., during a medication administration observation, LPN 4 administered 32 units of insulin glargine (long acting insulin) to Resident 17. LPN 4 did not prime the pen needle before administration. Upon completion of administration, LPN 4 indicated she did not prime insulin pen needles before administration.On 5/14/26 at 12:39 p.m., the DON indicated staff should prime the insulin pen before administration.Resident 17's clinical record was reviewed on 5/14/26 at 10:44 a.m. Diagnoses included diabetes mellitus and a physician order for insulin glargine inject 32 units at bedtime.A facility document, titled Insulin Injections, provided by the Infection Control Nurse, on 9/25/23 at 11:35 a.m., indicated the following under the heading Administering…
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 before2026-05-18 · 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
A. Based on observation, interview, and record review, the facility failed to provide adequate supervision for a cognitively impaired resident to prevent repeated falls for 1 of 4 residents reviewed for falls (Resident 45).B. Based on interview, observation, and record review, the facility failed to provide safe bed mobility assistance for a dependent resident which resulted in the resident being rolled out of the bed and onto the floor by staff for 1 of 4 residents reviewed for falls (Resident 7). Findings include: A1. During an observation, on 5/11/26 at 12:16 p.m., Resident 45 sat in a wheelchair in the dining room at a table. His face was bruised on the right side of his face, around his eye. On 5/12/26 at 10:20 a.m., Resident 45 attempted to stand on his own three times. CNA 14 attempted to assist the resident to a wheelchair. She was unable to complete the transfer on her own and asked CNA 15 to assist her with the resident's transfer. Once the resident was transferred, he immediately stood up again and was unwilling to sit down. CNA 14 asked him if he needed to use 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 · E2025-04-09 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 and interview, the facility failed to prepare and distribute food in a safe and sanitary manner. This deficient practice has the potential to affect 46 of 46 residents who receive meals from the Transitional Care Unit and Tulip Place kitchenette. Finding includes: During a meal service observation on 4/4/25 at 11:30 a.m., Dietary [NAME] 8 donned gloves and utilized utensils to scoop food items onto plates, warmed up a cooked hamburger on the griddle, picked up the mustard container with his gloved hands, and applied mustard to the hamburger. While wearing the same gloves, Dietary [NAME] 8 removed an egg roll from inside a warmer and placed it onto a resident's plate. He prepared four more resident's plates dipping up the stir fry and rice with utensils and placing the egg rolls on the plates with his gloved hands. He doffed his gloves, washed his hands with soap and water, and donned new gloves. Dietary [NAME] 8 used his gloved hand to place a plate on the serving board. He used the same gloved hand to remove an egg roll from inside the warmer and placed it on a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-09 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY A6. During an observation on 4/2/25 at 4:52 p.m., CNA 15 approached Resident 153's room, where a droplet isolation sign was in place at the door. The droplet isolation sign indicated everyone was required to perform hand hygiene before entering and when leaving the room. A face shield or goggles was required. The face protection was required to be removed prior to exiting the room. She donned a gown and gloves, and entered the resident's room. CNA 15 already had a surgical mask in place when she approached the resident's room. The mask was not changed when she entered the room and delivered a cup of water to the resident. She wore regular eyeglasses. Eye protection was not worn during the observation. CNA 15 doffed her gown and gloves and exited the room at 4:54 p.m., without removing her surgical mask. She continued to deliver water to random residents' rooms on the Cedar Ridge Unit. Resident 153's clinical record was reviewed on 4/4/25 at 10:52 a.m. Diagnoses included influenza due to identified novel…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-09 · 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 observation, record review, and interview, the facility failed to promote resident dignity by failing to provide prompt care for bowel incontinence for 1 of 1 resident reviewed for dignity. (Resident 71) Finding includes: Confidential interviews were conducted during the course of the survey. During the confidential interview, the interviewee indicated Resident 71 had been assisted into a wheelchair and out of his room that day. The resident indicated he had been having a bowel movement as he left the room. He was not permitted to return to his room because his room was being sprayed for pests. The room had been sprayed about an hour ago. The resident had been in the common area since he had left his room. The staff members were aware the resident was soiled, but did not know what to do and did not know how to help him get changed as they were not permitted to return to the resident's room due to the exterminator's spray. During an interview on 4/7/25 at 2:36 p.m., Resident 71 indicated his room had been treated today for pests, and he had to stay out of his room. He was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-09 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 who self-administered medications were assessed for safety for 2 of 2 residents reviewed for medication self-administration. (Residents 31 and 14) Findings include: 1. During an interview on 4/2/25 at 3:09 p.m., a medication cup sat on Resident 31's bedside table. She indicated the cup contained applesauce and her medications. A large, red-colored pill and white colored pills were observed in the cup. The resident indicated the pills had to dissolve in the applesauce before she could swallow them. Staff left the medications with her because the pills took a long time to dissolve. Resident 31's clinical record was reviewed on 4/8/25 at 4:19 p.m. Diagnoses included atrial fibrillation, major depressive disorder, anxiety disorder, heart failure, and acute kidney failure. Current physician's orders included levothyroxine sodium 75 micrograms (mcg) (thyroid medication), one tablet in the evening, gabapentin 100 mg (seizure or nerve pain medication), two capsules twice a day, mechanical soft diet,…
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 before2025-04-09 · 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 monitor bowel movements and initiate the facility's bowel protocol for a resident with constipation for 1 of 1 resident reviewed for constipation. (Resident 40) Finding includes: During an interview on 4/7/25 at 1:57 p.m., Resident 40 indicated her bowels moved that day, but it was very hard. It had been about three days since her bowels last moved. She hoped the constipation was getting better. Resident 40's clinical record was reviewed on 4/7/25 at 4:34 p.m. Diagnoses included Parkinson's disease, constipation, generalized anxiety disorder, unspecified dementia, iron deficiency anemia, and difficulty walking. A current physician's order included bisacodyl rectal suppository 10 mg insert one suppository rectally as needed for constipation daily, An admission Minimum Data Set (MDS) assessment, dated 12/16/24, indicated the resident was moderately cognitively impaired, used a manual wheelchair, required set-up assistance for eating, toileting, and oral hygiene. She could walk 10 feet with supervision. The resident was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 14 citations
- Potential for harm · Dcited before2025-04-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
A. Based on observation, record review, and interview, the facility failed to implement interventions to promote the healing of a pressure injury for 1 of 4 residents reviewed for pressure injuries. (Resident 71) B. Based on observation, record review, and interview, the facility failed to utilize infection prevention and control strategies to promote the healing of a pressure injury for 1 of 4 residents reviewed for pressure injuries. (Resident 153) Findings include: A.1. Confidential interviews were conducted during the course of the survey. During the confidential interview, the interviewee indicated Resident 71 had been assisted into a wheelchair and out of his room that day. The resident indicated he had been having a bowel movement as he left the room. He was not permitted to return to his room because his room was being sprayed for pests. The room had been sprayed about an hour ago. The resident had been in the common area since he had left his room. The staff members were aware the resident was soiled, but did not know what to do and did not know how to help him get changed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-09 · tag F0865 — failed to run a quality-improvement (QAPI) program — isolatedHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to develop and implement approaches to maintain a Quality Assurance and Performance Improvement (QAPI) program to prevent repeat deficiencies. Finding includes: 1. Review of the Summary Statement of Deficiencies, for the facility's last annual Recertification and State Licensure Survey completed on 5/1/24, indicated the facility failed to provide monitoring of a pressure injury and failed to develop and implement interventions to promote the healing of pressure injuries. The plan of correction indicated, .the DON or designee, will audit four (4) resident's dressing changes one (1) time a week for four (4) weeks then one (1) time a month for five (5) months for potential infection related to contamination for example, glove use and hand hygiene - Before handling clean or soiled dressings, gauze pads, - After handling used dressings, contaminated equipment, - After contact with objects in the immediate vicinity of the resident. Results of these audits will be forwarded to QAPI. Any negative findings will add an additional month…
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 · D2024-11-25 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to prevent staff-to-resident verbal abuse of a dependent resident (Resident D) and neglect of a resident (Resident E) from a staff member, CNA 1, for 2 of 3 residents reviewed for abuse. The deficient practice was corrected on [DATE], prior to the date of the survey, and was therefore past noncompliance. Findings include: 1. The clinical record for Resident D was reviewed on [DATE] at 10:57 a.m. Diagnoses included dysphagia, cerebral infarction, and glaucoma. The most recent significant change Minimum Data Set (MDS) assessment, dated [DATE], was reviewed on [DATE] at 10:57 a.m. The MDS indicated Resident D had severe cognitive impairment and was dependent on staff for all activities of daily living. In a written statement, dated [DATE], CNA 2 indicated while getting Resident D ready for bed, Resident C indicated CNA 2 had told Resident D to Shut up, You don't need to talk right now. CNA 1 also told the resident that she would give her permission to talk.…
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 · D2024-06-07 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to report accurate information regarding an elopement for 1 of 1 facility reported incidents reviewed for elopement (Resident B). Findings include: A Facility Reported Incident indicated the following: The actual or identified date and time of the incident was 5/23/24 at 9:30 p.m. Resident B was admitted to the facility on [DATE] for rehab services. Upon admission he was identified as moderately cognitively impaired, and he was an elopement risk. A discussion with the family regarding his risk for elopement resulted in the family declining a need for his placement on a secured unit. On 5/24/24 at 6:10 a.m., CNA 7 went into Resident B's room to check on him, discovered he was not in his room, and she alerted LPN 16. Resident B was located outside of the facility and returned without incident. The clinician and the family were notified and in agreement to relocate Resident B to a room within a secured unit. There was no physical, mental or emotional injury…
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 before2024-05-01 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to follow physician orders regarding blood glucose monitoring, insulin administration, and elastic wraps (for swelling) for 2 of 26 residents reviewed for following physician orders. (Residents 90 and 82) Findings include: 1. Resident 90's clinical record was reviewed on 4/26/24 at 3:34 p.m. Diagnoses included type 2 diabetes mellitus and hypothyroidism. A current physician order, dated 3/28/24, indicated metformin (diabetes medication) 1000 milligrams (mg), give 1 tablet by mouth twice a day. A physician order, dated 6/18/23, included check blood sugar two times daily. The order was discontinued on 4/22/24. A physician order, dated 7/1/23, included Novolog Flexpen (insulin for diabetes) 100 units/milliliters, inject subcutaneously every morning and at bedtime per sliding scale: if blood glucose is 150 - 200 = 2 units, 201 - 250 = 4 units, 251-300 = 6 units, 301-350 = 8 units, 351 - 400 = 10 units. The order was discontinued on 4/22/24. A quarterly Minimum Data Set (MDS) assessment, dated 3/1/24, indicated 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 · Dcited before2024-05-01 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During an observation, on 4/25/24 at 11:06 a.m., Resident 120 was seated in his recliner with his legs elevated. He had a dressing to his left heel and wore non-slip socks. During an observation, on 4/26/24 at 9:56 a.m., Resident 120 was fully dressed. He was seated in his recliner with non slip socks to bilateral feet. During an observation, on 4/29/24 at 10:08 a.m., Resident 120 was seated in his recliner with non slip socks on his bilateral feet. A pair of pressure relief boots were on the top of the dresser. Two handwritten signs were taped to the dresser doors in his room and indicated the following: Wear pressure relief boots to bed. Left boot at all times. During a catheter care observation, on 4/29/24 at 2:27 p.m., QMA 23 and CNA 24 indicated Resident 120 did not have his offloading boot on his left foot. His left foot dressing was dated 4/28/24. During an observation, on 4/30/24 at 12:08 p.m., Resident 120 was seated in the dining room. He wore non-slip socks to his bilateral feet. He was not wearing…
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 before2024-05-01 · tag F0744 — failed to care for residents with dementia — isolatedProvide 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 observation, interview, and record review, the facility failed to develop and implement a system of individualized behavior monitoring and management that provided information for assessment to develop individualized interventions to prevent recurrence of behavior expressions for 1 of 4 residents reviewed for dementia services (Resident 85). Findings include: During an observation on 4/24/24 at 12:27 p.m., Resident 85 was seated in a wheelchair in the lounge area. He was calm. During an observation on 4/25/24 from 9:51 a.m. to 10:00 a.m., the resident was seated a chair in the lounge attending a remembering activity. He was calm. During an observation on 4/30/24 at 11:04 a.m., the resident was seated in a wheelchair in the lounge. His eyes were closed and his chin was to his chest. During an observation on 4/30/24 at 2:50 p.m., the resident was seated in a wheelchair in the lounge. His eyes were closed and his chin was to his chest. Resident 85's clinical record was reviewed on 4/30/24 at 9:55 a.m.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-01 · 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 and interview, the facility failed to ensure medications were labeled with resident identifiers and directions for 2 of 5 medication carts reviewed. (Rehabilitation Cart 1 and Rehabilitation Cart 2) Findings include: 1. During an observation on 4/29/24 at 9:30 a.m., accompanied by QMA 20, the Rehabilitation Unit Medication Cart 2 contained an opened and unlabeled bottle of morphine sulfate oral solution (to treat pain) 100 milligram (mg)/5 Milliliters (ml), in the narcotic drawer. The bottle lacked identifiers and directions. During an interview, at the time of observation, QMA 20 indicated the opened bottle of morphine sulfate oral solution lacked a label or resident identification. She was uncertain why it was not labeled. All medications required labels regardless of where the medications came from. Medication labels were required to include the following: resident identifiers, drug name, drug dose, route of administration, and directions for use. She had not administered the medication, but was aware to whom the medication belonged to since she received 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 · Dcited before2024-05-01 · 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 utilize infection prevention and control strategies to prevent contamination of wounds during wound care for 2 of 3 residents reviewed for skin conditions. (Residents 154 and 467) Findings include: 1. Resident 154's clinical record was reviewed on 4/26/24 at 10:57 a.m. Diagnosis included necrotic pancreatitis, generalized muscle weakness, and need for assistance with personal care. A current physician order, dated 4/9/24, indicated to cleanse the resident's abdominal wound from gastrostomy tube removal with normal saline and gauze, pat dry, and apply skin preparation every night. A current physician order, dated 4/23/24, indicated to provide a treatment to the abdominal wounds daily, as needed every night shift, and as needed for soilage and dislodgement. Cleanse the abdominal wounds with normal saline and gauze, pat dry, apply skin prep to periwound, and apply foam. A current physician order, dated 4/24/24, included Keflex (antibiotic) 500 mg capsule, give one capsule by mouth two times a day for seven days…
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 before2024-04-18 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to identify effective, individualized interventions to prevent the elopement of a cognitively impaired resident with known elopement risk from a secured unit's bedroom window for 1 of 3 residents reviewed for elopement risk. (Resident C) The deficient practice was corrected on 3/26/24, prior to the start of the survey, and was therefore past noncompliance. Findings include: On 4/16/24 at 10:43 a.m., Resident C was observed sitting on a facility chair, participating in a group activity near the fireplace on the [NAME] Way Unit. On 4/18/24 at 12:12 p.m., the resident was observed leaving the secured unit with family. Resident C's clinical record was reviewed on 4/16/24 at 12:36 p.m. Diagnoses included, but were not limited to, cerebral infarction, metabolic encephalopathy, weakness, other muscle spasm, depression, memory deficit following unspecified cerebrovascular disease, hemiplegia and hemiparesis following cerebral infarction, affecting…
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 · D2024-01-19 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a resident's narcotic medication was free from diversion for 1 of 1 resident reviewed for misappropriation of medication (Resident B). The deficient practice was corrected on 10/10/23, prior to the start of the survey, and was therefore past noncompliance. Findings include: Resident B's clinical record was reviewed on 1/17/24 at 10:00 a.m. Diagnoses included unspecified sequelae of cerebral infarction, difficulty in walking, weakness, other lack of coordination, need for assistance with personal care, acquired absence of left leg below knee, carcinoma in situ of bladder, and chronic pain syndrome. His medications included oxycodone-acetaminophen (narcotic pain medication) 7.5-325 mg (milligram) three times daily and oxycodone-acetaminophen 7.5-325 mg every six hours as needed (PRN) for chronic pain. He had a care plan for receiving pain medication related to cancer (9/19/23). His October 2023 Medication Administration Record (MAR) indicated LPN 6 gave Resident B an oxycodone-acetaminophen 7.5-325 mg at 6:00 a.m. 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 · F2023-08-23 · tag F0919 — failed to provide a working call system — widespreadMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the call light system was operational. This deficiency had the potential to effect 161 of 161 residents living in the facility. Findings include: During an interview on 8/23/2023 at 10:17 a.m., the Administrator indicated between 8/10/2023 and 8/15/2023, the call light system had been worked on. After the call system technician left, it was discovered the call lights were not transferring to the pagers (used to alert staff). The facility started doing 15 minute rounding on the residents. The call system technician was called and an attempt to trouble shoot over the phone was made. The Administrator indicated she checked the call lights and found the system functioned sporadically. The next day, the call system technician returned to the facility at 9:00 a.m., and discovered the resident's call pendants were not working. The 15 minute rounding continued. The call system technician reprogrammed the equipment. The facility was rounded on at 9:30 a.m.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-05-01 · tag F0732 — widespreadPost nurse staffing information every day.
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 make nursing staffing data readily available in a prominent, easily accessible location for residents and visitors. Findings include: On 4/25/24, at 2:15 p.m., a binder labeled Nursing Daily Schedules was located at the reception desk on a raised ledge. The binder contained schedules for 4/25/24, but lacked hours worked and specific nursing roles, such as RN and LPN. At the same time, Receptionist 19 indicated she did not know where to find the nurse staffing posting. During an observation of the Evergreen Park unit, on 4/25/24 at 2:18 p.m., no staffing information was posted. During an observation of the [NAME] Way unit, on 4/25/24 at 2:21 p.m., no staffing information was posted. During an observation of the Magnolia Lane unit, on 4/25/24 at 2:26 p.m., no staffing information was posted. During an observation on 4/29/24 at 9:15 a.m., no staffing information was posted. During an observation of the Health Care [NAME] unit, on 4/25/24 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.
- No harm found · C2024-05-01 · tag F0839 — widespreadEmploy staff that are licensed, certified, or registered in accordance with state laws.
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 an LPN employed to work in the facility in the nursing department had a valid Indiana nursing license or an active out of state license valid through an interstate compact agreement (LPN 3). This deficient practice had the potential to impact 164 of 164 residents who resided in the facility. Finding include: Employee records, completed by the facility, were reviewed on 4/29/24. LPN 3 was listed on the form as an LPN Supervisor. The form indicated the nurse had been employed by the facility since 2/27/23. A facility-provided binder containing nursing licenses verification for facility employees, indicated LPN 3 held a Texas Board of Nursing, License Type-LPN, Compact Status-Single State. The Texas Board of Nursing verification form, which listed single state had a run and print date of January 2024 (3 months prior to the review). During an interview on 4/29/24 at 1:30 p.m., the Human Resources Director indicated she would review the compact status of LPN 3 and provide additional information. 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.
“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
$22,071 in federal fines across 2 penalties.
- $12,038 — penalty dated 2024-06-07
- $10,033 — penalty dated 2024-04-18
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| WOODLAWN HOSPITAL | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 10/31/2014 |
| BODE, GLEN | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 12/09/2022 |
| CHUDZYNSKI, KENDRA | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 10/15/2024 |
| FISHER, ALAN | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | — | since 06/13/2022 |
| HEYDE, ALISON | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 09/01/2019 |
| JOHNSON, TERRI | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 06/13/2022 |
| MELLINGER, GREGORY | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 06/13/2022 |
| MILLER, BRANDON | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 04/07/2025 |
| WEBB, HARRY | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 10/15/2023 |
| ALL POINTS MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2021 |
| LIFE CARE SERVICES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/31/2014 |
| THE ESTELLE PEABODY MEMORIAL HOME OF THE SYNOD OF LINCOLN TRAILS OF UN | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/31/2014 |
| FEUER, SAMUEL | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/12/2022 |
| KATZ, LARRY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/12/2022 |
| PATEL, RUTVIK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2014 |
| ROBINSON, KATIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/10/2023 |
| SOKOLOW, STEPHEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/12/2022 |
| TOPLIFF, TODD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2021 |
| LAHASKY, EPHRAM | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 12/17/2025 |
| SCHLITT, ALBERT | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 12/17/2025 |
| WEISZ, MORDECHAI | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 12/17/2025 |
| ALLEN COUNTY INTERNAL MEDICINE | Organization | ADP OF THE SNF | — | since 07/01/2015 |
| AR SOLUTIONS LLC | Organization | ADP OF THE SNF | — | since 11/01/2024 |
CMS files one row per role, so the 38 rows in the source record cover these 23 parties — each is shown once here with every role it holds. Nothing is omitted.
6 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.
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 155655. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-18, 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.