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Majestic Care Of North Vernon

701 Henry Street, North Vernon, IN 47265 · Non profit - Corporation · 120 certified beds · (812) 346-9333 Medicare & Medicaid certified

Call the home — (812) 346-9333 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0604, F0609, F0610) — most recent Mar 20261 actual-harm citation
Insights

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

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • about 22% of its spending goes to commonly-owned related companies

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 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

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
Pharmacy
939 Veterans Dr Ste B · (812) 352-9700 · Call to confirm hours
Grocery
1357 N State St · (812) 346-7989 · Call to confirm hours
Park
604 N State St · (812) 346-9371 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased4.1%11.0%15.4%better
Long-stay residents who lose too much weight3.0%5.5%5.4%better
Long-stay residents with a catheter left in their bladder0.3%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%1.1%2.0%better
Long-stay residents with depressive symptoms39.1%25.2%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury3.7%3.9%3.3%worse
Long-stay residents whose ability to walk worsened6.8%11.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication25.2%23.5%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.4%95.3%typical
Long-stay residents with pressure ulcers1.7%3.6%4.7%better
Long-stay residents with worsening bladder/bowel control24.4%23.3%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table14.1%13.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%79.0%79.4%better
Short-stay residents rehospitalized after admission13.8%22.2%22.6%better
Short-stay residents with an outpatient ER visit4.2%10.8%12.0%better
Long-stay hospitalizations per 1,000 resident days0.531.611.67better
Long-stay outpatient ER visits per 1,000 resident days2.141.441.80worse

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

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

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

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

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

48.1% 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 51 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

48.1%U.S. median 51.5%
Got home and stayed home
10.8%U.S. median 10.7%
Went back to hospital
20.8%U.S. median 56.6%
Met the expected recovery
0.09U.S. median 0.31
Therapy hours / resident / day
0.01hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 20.8% 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 24 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 0.09 therapist hours per resident per day in 2026Q1 — more than 5% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 25% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF48.1%CMS range 38.1–58.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.8%CMS range 6.9–16.610.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge20.8%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge12.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge33.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.1%CMS range 4.0–13.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.331.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.32
RN hours/ resident / day
0.88
LPN hours/ resident / day
2.07
Aide hours/ resident / day
3.27
Total nurse hours/ resident / day
0.19
RN hoursweekends
48.2%
Total nursing turnover
44.4%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 94.7 residents a day — about 79% occupied, or roughly 25 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 3.27 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 2.07 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 2.75 hrs/resident/day on weekends vs 3.49 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.38 to 0.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 48% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

8
deficiencies at the latest standard inspection (2025-06-12)
2
at the previous standard inspection (2024-07-02)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

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

  • Actual harm · G2023-05-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to prevent pressure ulcers that resulted in the development of Stage 3 pressure ulcers (Residents 16 and 103) and follow a physician's order (Resident 91) for 3 of 7 residents reviewed for pressure ulcers. Findings include: 1. During an observation of Resident 16's wound on 05/11/23 at 9:43 A.M., the Wound NP (Nurse Practitioner) cleansed the wound to the left heel. The area had slightly macerated skin. The wound bed was pink with no drainage. The wound measured 0.4 cm (centimeters) x (by) 0.4 cm. The Wound NP indicated she expected the wound to be macerated due to the treatment she had in place. The clinical record for Resident 16 was reviewed on 05/10/23 at 1:52 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 02/22/23, indicated the resident was rarely/never understood. The diagnoses included, but were not limited to, Alzheimer's disease, hypertension, anxiety, depression, and contracture. The resident required total staff assistance with transfers, locomotion, eating, toileting, personal hygiene,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-24 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to report a resident's allegation of abuse for 1 of 3 resident's reviewed for abuse allegations reviewed. (Resident C) Findings include:During an interview, on 03/23/2026 at 10:19 A.M., Resident C indicated she had been hit by Resident F in her left shoulder on Friday 03/20/2026. Resident C told the nurse, and another staff member in the front of the building. The nurse told her she would be okay. During an interview, on 03/23/2026 at 4:22 P.M., Licensed Practical Nurse (LPN) 2 indicated if there was an incident where a resident claimed to be hit by another resident, she would report it directly to the Administrator and Director of Nursing (DON) verbally. Outside of telling management verbally floor staff do not document about the occurrence. Management staff would be the ones to document the incident details. During an interview, on 03/23/2026 at 4:31 P.M., the Administrator indicated he was not informed about the incident that occurred on Friday until the Monday after. He had just begun his own investigation. During an…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-24 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to dispose of medications after discharge for 2 of 9 residents reviewed for pharmacy services. (Resident G and Resident H) Findings include:1.a. During an interview, on 03/23/2026 at 2:09 P.M., the Director of Nursing (DON) indicated medications that required refrigeration were kept in the facility medication room refrigerator on the Unit C Hallway. At one time Ozempic (a medication used for weight loss) was stored in the refrigerator in her office, but it was no longer stored there. During an observation and interview, on 03/23/2026 at 2:18 P.M., a miniature refrigerator in the back right corner of the Director of Nursing's office was observed with three Ozempic medications. Two separate Ozempic medications for Resident G and one for Resident H. The DON indicated both residents had been discharged from the facility. The clinical record for Resident G was reviewed on 03/24/2026 at 9:30 A.M. A Discharge - Return not Anticipated Minimum Data Set (MDS) assessment, dated 01/31/2026, indicated 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-24 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to appropriately store medications for 1 of 2 medication storage areas reviewed for Drug and Biologicals storage. (Director of Nursing Office) Findings include:During an observation, on 03/23/2026 at 2:18 P.M., a miniature refrigerator in the back right corner of the Director of Nursing (DON) office contained the following medication, vaccines, and personal food/drink items : Ozempic, two single dose vials of Prevnar 20 (pneumococcal 20 valent vaccine), two single dose vials of RSV (Respiratory Syncytial Virus vaccine), Unopened individually wrapped sandwich, dressing bottle half full, four 12 ounce cans of lemonade unopened, one bottle of water 3/4 full, and a personal water bottle. During an interview, on 03/23/2026 at 2:44 P.M., the DON indicated she had forgotten about the medications being in her refrigerator and resident medications should never be stored with personal food items. The current facility policy, titled Medication Storage, with a reviewed date of 12/12/2023, was provided by the DON 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-10-27 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide safe water temperatures for 5 of 9 resident bathrooms and 1 of 2 common area bathrooms observed. (Rooms C 101, C 102, D 114, D 115, D 116, and Women's Visitor Restroom)Findings include:During an observation, on 10/27/2025 at 10:35 A.M., the water in the Women's Visitor Restroom in the main hallway was hot to touch, not able to hold the hand under the water. The door was unlocked, unless it was in use and several residents had independently passed by the restroom.During an observation and interview, on 10/27/2025 at 10:40 A.M., Resident Room D 116's bathroom sink water was hot to touch. Resident E indicated she had no concerns with her water.During an observation, on 10/27/2025 from 10:47 A.M. to 11:01 A.M., the Maintenance Director checked the water temperatures in the following rooms:-Room D-116 the water temperature was 124.0 degrees Fahrenheit,-Room D-115 the water temperature was 122.5 degrees Fahrenheit,-Room D-114 the water temperature was 124.3 degrees Fahrenheit,-Room C-101 the water…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-10-16 · tag F0776 — isolated
    Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
    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 meet the needs of a resident related to image acquisition by a contracted x-ray staff member. The resident's arm was improperly positioned and she cried out for 1 of 3 residents reviewed for diagnostic services. The resident's arm resulted with a fracture. (Resident B)Findings include:During an observation, on 10/15/2025 at 9:12 A.M., Resident B was lying in bed, her eyes were closed. There were no signs of distress. The resident had a red cast on her right arm that went from her hand up past her elbow. The clinical record for Resident B was reviewed on 10/15/2025 at 9:23 A.M. An Annual Minimum Data Set (MDS) assessment, dated 08/21/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes, hypertension, neurogenic bladder, arthritis, and aphasia. The resident had physical impairments on one side of the upper and lower extremities.A Progress Note, dated 08/27/2025 at 9:49 P.M., indicated the resident was noted to have redness to both elbows,…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-28 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and record review, the facility failed to ensure staff treated a resident with respect and dignity for 1 of 3 residents reviewed. (Residents C)Findings include: During an interview on 07/28/2025 2:46 P.M., Certified Nurse Aide (CNA) 2 indicated in June of 2025 Resident C informed her she was hungry, and her cornbread was thrown away. CNA 2 then heard Licensed Practical Nurse (LPN) 3 talk about Resident C. LPN 3 stated that Resident C had asked her to microwave the cornbread she had saved from her lunch. LPN 3 agreed but told Resident C not to stand up while she was gone. Upon returning LPN 3 saw Resident C walking and told her she no longer can have the cornbread for not listening. LPN 3 then said she threw away the corn bread. CNA 2 reported it to her superiors. A facility document, dated 06/20/25 at 11:45 A.M., provided by the Director of Nursing (DON) on 07/28/25 at 3:18 P.M., indicated Resident C reported LPN 3 told her to sit down in her chair and not move until she got back. She pointed to the chair that was pushed in under the overbed table near the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-12 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    2. The D-Hall Dining room meal service was observed on 06/08/25 at 11:51 A.M. Certified Nurse Aide (CNA) 9 pushed a chair in the dining room using her hands, touched her nose with her left hand, sat down in a chair by three residents sitting at the table nearest the kitchen door, touched her face and ear with her right hand, then served a meal tray to Resident 6. CNA 9 touched the resident's plate and napkin, unrolled the napkin, took out the silverware, removed the foil from the resident's baked potato, chopped it up with the resident's fork holding the fork in her right hand, opened the resident's sour cream packet, and squirted the sour cream on the resident's potato. The resident picked up the fork and fed herself. CNA 9 used hand sanitizer then served a tray to another resident. During an interview, on 06/11/25 at 2:11 P.M., CNA 9 indicated when serving meal trays, staff were to use hand sanitizer after each tray and wash their hands after three to five trays. Staff were not to touch themself before serving meal trays. The current Handwashing-Hand Hygiene policy, with an…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-12 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow appropriate infection control guidelines during a wound dressing change, and for indwelling urinary catheter management for 4 of 21 residents reviewed for infection control. (Residents 2, 100, 101, and 15) Findings include: 1. A wound dressing change for Resident 2 was observed on 06/10/25 at 10:41 A.M., with Licensed Practical Nurse (LPN) 7 and LPN 10. The LPN's donned gowns in the hallway from a cart of supplies sitting next to the resident's room door. LPN 10 donned gloves. With her gloves on, she reached into her pocket on her scrubs, got her treatment cart keys out, and used them to open the cart. She gathered treatment supplies, took them into the resident's room, laid the supplies on the over bed table, went into the bathroom located in the resident's room, did not turn on the water or change gloves, came out with paper towels, and put the paper towels on the over bed table. LPN 10 opened several gauze pads and made a stack,…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-12 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    2. During an observation and interview, on 06/08/25 at 10:19 A.M., Resident 37 was sitting on the side of the bed in her room. There were three medication cups sitting on the resident's bedside table. One medication cup contained three small white capsules, the second one contained a large white capsule, and the third one contained a large round pill broke in half, a medium round peach colored pill, one large round pill, one medium round white pill. The resident indicated the medications were hers and the nurse had left them for her to take. No staff members were in or near the resident's room or in the hallway outside the resident's room. The clinical record was reviewed on 06/10/25 at 11:03 A.M. A Quarterly MDS assessment, dated 04/21/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, hypertension, heart failure, dementia, anxiety, and depression. During an interview, on 06/11/25 at 9:54 A.M., Licensed Practical Nurse (LPN) 3 indicated medications should not have been left at the resident's bedside. A resident should be…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-12 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to revise a resident's care plan related to prophylactic antibiotic usage for 1 of 21 residents reviewed for care plans. (Resident 58) Findings include: Resident 58's clinical record was reviewed on 06/11/25 at 3:24 P.M. A Quarterly Minimum Data Set assessment, dated 02/28/25, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, stroke, diabetes, and renal insufficiency. The resident had an indwelling urinary catheter. The resident's current physician's orders included, but were not limited to the following: - An open-ended physician's order, with a start date of 02/13/25, for Cephalexin (an antibiotic) 500 milligrams, once daily for prophylaxis for recurrent UTIs (Urinary Tract Infections). The resident's Electronic Medication Administration Records for February, March, April, May, and June 2025 indicated the resident received the antibiotic daily since 02/13/25. The resident's complete Care Plan Report was reviewed on 06/12/25 at 10:45 A.M. and lacked a care…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · Dcited before2025-06-12 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to follow physician's orders related to hold parameters for cardiac medications for 3 of 21 residents reviewed for quality of care. (Residents 58, 15, and 7) Findings include: 1. Resident 58's clinical record was reviewed on 06/11/25 at 3:24 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 02/28/25, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, stroke, hypertension, and coronary artery disease. The resident's current physician's orders included, but were not limited to, an open-ended order, with a start date of 01/11/25, for Midodrine 10 milligram (mg) tablet, three times a day. The resident was to receive one tablet by mouth, at 8:00 A.M., 12:00 P.M., and 8:00 P.M., for hypotension. The medication was to be held if the resident's systolic blood pressure (top number) was greater than 120. The Electronic Medication Administration Record (EMAR) for May 2025 indicated the resident received the medication when the systolic blood pressure was over…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure proper placement of a urinary catheter drainage bag for a resident that received prophylactic antibiotics for Urinary Tract Infections (UTIs) for 1 of 4 residents reviewed for indwelling urinary catheters. (Resident 58) Findings include: On 06/09/25 at 10:28 A.M., Resident 58 was observed in her room in bed. The resident's urinary catheter drainage bag was hanging on the side of her bed. Dark yellow urine with sediment was visible in the tubing. There was a mat on the floor next to the bed and the bed was in a lower position. About two inches of the drainage bag was resting on the bare floor in the space between the bed and the floor mat. Resident 58 was observed in the A-Hall dining room on 06/10/25 at 12:12 P.M. The resident's catheter drainage bag was hanging under her wheelchair, with about an inch of the drainage bag resting on the floor. Resident 58's clinical record was reviewed on 06/11/25 at 3:24 P.M. A Quarterly Minimum Data Set assessment, dated 02/28/25, indicated 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-12 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to follow physician's orders related to medication administartion for 1 of 21 residents reviewed for pharamcy services. (Resident 23) Findings include: During an observation, on 06/09/25 at 8:48 A.M., RN 4 sanitized her hands and prepared medications for Resident 23. After placing all the medications into a cup that included, but was not limited to, a Potassium Chloride Extended-Release 10 milliequivalent (MEQ) tablet, she poured the medications into a pouch, crushed the medications, placed them back into the medication cup, and added applesauce. The medications were administered to the resident. The current, open-ended physician's order, with a start date of 07/13/23, indicated the resident was to receive Potassium Chloride 10 MEQ Extended-Release tablet, once a day. The staff were to place the medication in applesauce and allow it to dissolve. The tablet was not to be crushed. During an interview, on 06/11/25 at 12:07 P.M., the Director of Nursing (DON) indicated if a physician's order stated to not crush 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-12 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to store medications appropriately related to outdated/undated medications for 3 of 4 medication carts observed. (A, B, and C Hall medication Carts) Findings include: The A-Hall Medication Cart was observed on [DATE] at 10:14 A.M., with Licensed Practical Nurse 2. The following was observed: - an unopened vial of insulin Lispro for Resident 59 that was undated, - an opened Symbicort inhaler for Resident 17 that was undated, and - an opened Albuterol inhaler for Resident 17 that was undated. The B-Hall Medication Cart was observed on [DATE] at 10:19 A.M., with LPN 6. The following was observed: - a Combivent inhaler for Resident 65, that was dated [DATE]. The C-Hall Medication Cart was observed on [DATE] at 10:27 A.M., with LPN 3. The following was observed: - an opened vial of Humalog for Resident 16 that was 3/4 full that was undated. The nurse indicated it came from the pharmacy on [DATE] and wrote that as the open date on the vial. During an interview 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-19 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to notify the physician of a change in condition for 1 of 3 residents reviewed for Notification of changes. (Resident B) Findings include: The clinical record for Resident B was reviewed on 12/19/24 at 10:38 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 01/10/24, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, non-Alzheimer's dementia, hypertension, anxiety, and depression. Consumption Charting, dated 01/30/24 at 10:50 A.M., indicated Resident B had eaten less than a quarter of his meal. Consumption Charting, dated 01/30/24 at 1:50 P.M., indicated Resident B had eaten less than a quarter of his meal. A Progress Note made by Registered Nurse (RN) 2, dated 01/30/24 at 4:30 P.M., indicated Resident B was lethargic. A Progress Note made by Licensed Practical Nurse (LPN), 3 dated 01/30/24 at 7:19 P.M., indicated Resident B was found unresponsive and without a pulse at 6:05 P.M. During an interview on 12/19/24 at 12:40 P.M., RN 2 indicated she 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-04 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to report an allegation of verbal abuse in a timely manner for 1 of 3 residents reviewed for reporting of alleged violations. (Resident C) Findings include: During an interview on 09/04/24 at 8:38 A.M., Resident C indicated that a girl that worked at the facility had called him a B last week. He was unsure of their name but believed other staff had reported it. During an anonymous staff interview, between 09/03/24 and 09/04/24, Staff 102 indicated that on 08/29/24, LPN (Licensed Practical Nurse) 3 was very rude to Resident C and was verbally abusive. The LPN was yelling at the resident over the top of the nurse's station. It was reported to the DON. During an anonymous staff interview, between 09/03/24 and 09/04/24, Staff 103 indicated that on 08/29/24, LPN 4 was cussing/yelling at Resident C and pointing her finger at him over the top of the nurse's station. The resident told her that she was upsetting him. She started to walk away from the resident and said, Someone better get him the F* away from me because the B*…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-04 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to appropriately investigate an allegation of abuse for 1 of 3 residents reviewed for abuse. (Resident C) Findings include: During an interview on 09/03/24 at 10:01 A.M., CNA (Certified Nurse Aide) 2 indicated she had heard that a nurse had gotten into a resident's face last Thursday, 08/29/24. She wasn't working at the time of the incident but had heard about it. She believed someone had reported it to the DON (Director of Nursing). During an anonymous staff interview, between 09/03/24 and 09/04/24, Staff 102 indicated that on 08/29/24, LPN (Licensed Practical Nurse) 3 was very rude to Resident C and was verbally abusive. The LPN had yelled at the top of her lungs that no one wanted to listen to his F*ing music. She was yelling at the resident over the top of the nurse's station. The nurse had turned away from the resident and said, You better get him the F* away from me. It was reported to the DON. During an anonymous staff interview, between 09/03/24 and 09/04/24, Staff 103 indicated that on 08/29/24, LPN 4 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-02 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to maintain residents' snack refrigerators related to the storage of non-food items and unlabeled food items, for 3 of 4 resident snack refrigerators reviewed. (C-Hall, A-Hall, and D-Hall snack refrigerators) Findings include: 1. The C-Hall resident snack refrigerator was observed on 07/02/24 at 9:40 A.M., with LPN (Licensed Practical Nurse) 2. An ice pack was lying in the bottom bin of the freezer. The nurse indicated Resident 67 occasionally used it for their shoulder and resident items should be labeled with a name and a date. 2. The A-Hall resident snack refrigerator was observed on 07/02/24 at 9:47 A.M., with LPN 3. The freezer contained six small tubs of ice cream that were sitting right next to a large blue ice pack. The nurse indicated the ice pack was for a resident who had been discharged . The resident had used the ice pack following a knee replacement surgery. 3. The D-Hall resident snack refrigerator was observed on 07/02/24 at 9:59 A.M., with RN 4. The refrigerator contained a pudding cup that was opened, half…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-02 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to provide a homelike environment related to odors for 1 of 4 Hallways reviewed. (B- Hall) Findings include: During an observation on 06/26/24 at 11:05 A.M., there was a strong urine odor upon entering the B-Hall secured unit. During an observation on 06/26/24 at 12:34 P.M., there was a strong urine odor in the B-Hall dining room during mealtime. A sticky substance with a foul urine odor was on the floor causing resistance when walking next to the juke box in the common area. During an observation on 06/27/24 at 10:00 A.M., there was a strong urine odor upon entering the B-Hall secured unit. During an observation on 06/28/24 at 9:40 A.M., there was a strong urine odor upon entering the B-Hall secured unit. The odor was observed while walking down the hallway on the unit, and in the common area. During an observation on 06/28/24 at 2:11 P.M., a strong urine odor was in the common area/dining room of the B-Hall secured unit. During an observation on 07/01/24 11:45 A.M., residents 95's room smelled strongly of urine. 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-29 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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 a resident from being physically restrained for 1 of 3 residents reviewed for restraints. (Resident B) Findings include: During an interview on 01/28/24 at 2:35 P.M., LPN (Licensed Practical Nurse) 6 indicated there was an incident last month where a CNA (Certified Nurse Aide) put a blanket around a resident. A staff member indicated they entered the memory care unit and saw the blanket around Resident B. That staff member reported it to another staff member, and that person reported it to LPN 6. LPN 6 got the Weekend Manager and they both went to check it out. The resident was sitting in her wheelchair. A blanket was wrapped around the resident at her waist, and it was tied in the back. The resident's clinical record was reviewed on 01/29/24 at 10:00 A.M. A Significant Change MDS (Minimum Data Set) assessment, dated 11/21/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, dementia, manic depression, psychotic disorder, and malnutrition. The resident…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-15 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and observation, the facility failed to complete Neurological Evaluations/Checks following falls for 3 of 22 residents reviewed for Quality of Care. (Residents 32, 22, and 69) Findings include: 1. The clinical record for Resident 32 was reviewed on 05/11/23 at 11:01 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 03/17/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, hypertension, anxiety, depression, and COPD (Chronic Obstructive Pulmonary Disease). The resident received special treatments while in the facility that included, but was not limited to, oxygen therapy. The resident required extensive assistance of one staff member for transfers and toileting. The resident had two or more falls, with injuries that were not major, since the last assessment, a Significant Change assessment dated [DATE]. An Event Note, dated 02/18/23 at 9:49 A.M., was provided by the DON (Director of Nursing) on 05/15/23 at 8:30…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement Care Plan interventions for 1 of 5 residents reviewed for falls in the facility. (Resident 32) Findings included: The clinical record for Resident 32 was reviewed on 05/11/23 at 11:01 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 03/17/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, hypertension, anxiety, depression, and (COPD) Chronic Obstructive Pulmonary Disease). The resident required extensive assistance of one staff member for transfers and toileting. The resident had two or more falls, with injuries that were not major, since the last assessment, a Significant Change assessment dated [DATE]. An IDT (Interdisciplinary Team) note, dated 12/12/22 at 10:03 A.M., was provided by the DON (Director of Nursing) on 05/15/23 at 8:30 A.M. The note indicated the resident had an unwitnessed fall on 12/09/22 at 5:42 A.M., in her room. The resident complained of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-15 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to administer oxygen as ordered by the physician for 1 of 2 residents reviewed for Respiratory Care. (Resident 32) Findings include: During an observation on 05/08/23 at 11:50 A.M., CNA (Certified Nurse Aide) 8 brought Resident 32 out of the bathroom in her wheelchair. The resident was not wearing oxygen. The CNA turned on the oxygen concentrator machine sitting at the side of the resident's bed and assisted the resident with her oxygen tubing. The tubing was rolled up in a plastic bag hanging on her machine. The CNA placed the nasal cannula appropriately under the resident's nose. The oxygen was observed to be set on 2.5 liters per minute. During an observation on 05/10/23 at 11:23 A.M., the resident's oxygen concentrator was set at 2.5 liters per minute. The resident was lying in bed wearing her oxygen nasal cannula. During an observation and interview on 05/12/23 at 9:53 A.M., with the Weekend Nursing Supervisor, the resident's oxygen…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-15 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to appropriately follow the physician's orders related to once a day medication administration for 1 of 6 residents reviewed for pharmacy services. (Resident 98) Findings include: Resident 98 was observed in her room on 05/10/23 at 11:26 A.M. The resident indicated she had been experiencing stomach issues for the last few months. She had some pain, but mostly she was just nauseated all the time. The NP (Nurse Practitioner) adjusted some of her medications and started her on some new medications. She was supposed to have a consult with a specialist soon. She felt like she was taking too many pills for her stomach. The resident's clinical record was reviewed on 05/12/23 at 1:21 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 02/15/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, major depressive disorder, hypertension, diabetes, quadriplegia, depression, and schizophrenia. A physician's order, dated 03/01/23, indicated the resident was to receive…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-15 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to store medication appropriately for 3 of 4 medications carts and 1 of 1 medication rooms observed. (A-Hall, B-Hall, and D-Hall medication carts and the facility medication room) Findings include: 1. During an observation and interview on 05/15/23 at 11:41 A.M., the B-Hall Medication Cart was observed with QMA (Qualified Medication Aide) 2. The cart contained an undated bottle of Lantus (an insulin medication) that was full. The medication bag indicated the medication was dispensed on 05/11/23. The QMA indicated the resident was newly admitted to the facility and already had an opened bottle of the Lantus in the medication cart that was opened on 05/12/23. The medication should have been put in the refrigerator until it was ready to be used. The resident received 25 units at bedtime. 2. During an observation on 05/15/23 at 11:44 A.M., the D-Hall Medication Cart was observed with RN 12 the cart contained the following: - a bottle of Humalog (an insulin medication) for Resident 56 was almost full, with an open date of 04/12/23,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-15 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to maintain residents' snack refrigerators related to unlabeled items, outdated items, and the storage of non-resident food items for 2 of 3 resident snack refrigerators reviewed. (Dementia unit and C-Hall snack refrigerators) Findings include: 1. The nourishment area on the Dementia unit was observed with QMA (Qualified Medication Aide) 2 on 05/15/23 at 10:13 A.M. The snack refrigerator contained the following: - A nearly empty two-liter bottle of soda. QMA 2 indicated it belonged to a resident. There was no label that indicated which resident it belonged to, - A less than half full clear pitcher of orange juice dated 05/08/23, - A less than a quarter full clear pitcher of reddish purple colored juice dated 05/08/23, - A half full clear pitcher of orange drink dated 05/11/23, and - A plastic grocery bag in the freezer that contained brine shrimp fish food for the fish tank. During an interview on 05/15/23 at 10:13 A.M., QMA 2 indicated resident items brought in from home should be labeled. The drinks were good for 3 days after…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-15 · tag F0867 — failed to act on quality-improvement findings — isolated
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to demonstrate that ongoing corrective actions were in place to address unresolved quality deficiencies related to pressure ulcers, that were previously cited on the last annual survey, for 4 of 7 residents reviewed for pressure ulcers. Findings include: The current facility policy, titled Quality Assessment and Performance Improvement (QAPI) Plan, with a revised date of 10/03/17, was provided by the Administrator following the Entrance Conference on 05/08/23. The policy indicated, .This facility shall develop, implement, and maintain an ongoing, effective, comprehensive, facility-wide .QAPI .Program that focuses on indicators of the outcomes of care and quality of life .The Plan covers all systems of care .including .clinical care . During this annual Recertification survey, from 05/08/23 to 05/15/23, one deficiency was a repeated citation from the last annual survey, F686. The facility's Quality Assurance Committee did not implement on-going appropriate measures to correct identified issues or prevent deficiencies as…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-05-15 · tag F0572 — widespread
    Give residents a notice of rights, rules, services and charges.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure resident rights were posted and readily accessible to 107 residents who resided in the facility. Findings include: During the Resident Council meeting on 05/11/23 at 2:14 P.M., the group indicated they were aware the resident rights were signed upon admission. They were unaware where the resident rights were posted in the facility. During an interview on 05/15/23 at 11:25 A.M., the Administrator indicated the resident rights could be found in each resident's admission packet but, he was unaware where the resident rights were posted in the facility. During a walk through of the facility on 05/12/23 at 11:26 A.M., the Administrator stopped by the admissions office, she was unaware where the resident rights were posted in the facility. He stopped by the Social Services office, she too was unaware of where the resident rights were posted in the facility. During an interview on 05/12/23 at 11:29 A.M., the Administrator indicated when the facility walls were painted, approximately two months ago, the resident rights were…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to MAJESTIC CARE — 22 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.5-0.5 vs chain
Health inspection 2 of 52.1-0.1 vs chain
Staffing 1 of 51.7-0.7 vs chain
Quality measures 5 of 54.5+0.5 vs chain
The other 21 homes this chain runs (chain average 2.5★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
DAVIESS COUNTY HOSPITALOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 04/03/2025
STEINER, DERONIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2025
CHAMBERLAIN, MARGARETIndividualCORPORATE OFFICERsince 09/11/2023
PRUITT, PAULIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
SETTLES, APRILIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2025
SHATROV, ANZHELIKAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
MAJESTIC CARE OF NORTH VERNON LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/03/2025
MAJESTIC MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/03/2025
ALEXANDER, DAVIDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
KERN, DANIELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
MARX, DAVIDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
NEESE, KEVINIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
REWA, ANGELAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
RUSSELL, ROBERTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
WOLFE, ERICIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
701 HENRY SNF REALTY LLCOrganizationADP OF THE SNFsince 06/01/2018
MDG REAL ESTATE GLOBAL LIMITEDOrganizationADP OF THE SNFsince 06/01/2018

CMS files one row per role, so the 34 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted.

5 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.

$13.1M
Net patient revenuemost recent cost report
+5.8%
Operating marginrevenue minus expenses
$2.7M
Related-party expense22% of expenses
Who pays — share of resident-days
Medicaid 78%Medicare 6%Other / private 15%

About 78% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.7M paid to related parties — landlords or management companies under common ownership — equal to about 22% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$319per resident / day
operating cost
$9,704per month
≈ monthly operating cost
$339per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IN

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Indiana Medicaid page.

Typical monthly cost in Indiana
$8,943/mo
Nursing home (semi-private)
$10,326/mo
Nursing home (private)
$5,639/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 155665. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-12, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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