Oak Village
200 W Fourth St, Oaktown, IN 47561 · For profit - Corporation · 50 certified beds · (812) 745-2360 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- about 17% 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 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.
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 | 26.6% | 11.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.4% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 2.9% | 0.4% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.9% | 1.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 47.1% | 25.2% | 6.5% | worse 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 | 4.6% | 3.9% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 21.1% | 11.9% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 13.5% | 23.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 96.7% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.1% | 3.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 32.0% | 23.3% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.1% | 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 | 72.7% | 79.0% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 42.3% | 22.2% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 8.7% | 10.8% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.75 | 1.61 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.71 | 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.
48.3% 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 25 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.39 therapist hours per resident per day in 2026Q1 — more than 66% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| 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 | 48.3%CMS range 32.1–65.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.7%CMS range 7.2–16.7 | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 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 next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.1%CMS range 3.0–13.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.86 | 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 50 beds and averages 36.2 residents a day — about 72% occupied, or roughly 14 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 3.29 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.81 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.82 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 2.87 hrs/resident/day on weekends vs 3.45 on weekdays — 17% thinner on weekends. RN hours go from 0.88 to 0.63 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 53% 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.
25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.
- Potential for harm · Ecited before2025-12-22 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to develop and implement resident's plan of care based on current status for 1 of 1 resident reviewed for pressure ulcers, 3 of 5 residents reviewed for accidents, and 1 of 5 residents reviewed for unnecessary medications. A resident lacked a care plan for a current stage 3 pressure ulcer, lacked a care plan for behavior of cannabis smoking, lacked a care plan for antiplatelet medication, and not following fall interventions. (Resident 28, Resident 9, Resident 1, Resident 30, Resident 5)Findings include:1. During an observation on 12/18/25 at 10:48 A.M., Resident 5 was observed in the common area by the nurses' station in his wheelchair. The facility failed to have any activities available to the resident while seated in the wheelchair. During an observation on 12/18/25 at 11:36 A.M., Activities Assistant 4 pushed Resident 5 to the dining room to eat. Multiple residents entered the dining room after Resident 5. On 12/16/25 at 1:29 P.M., Resident 5's clinical record was reviewed. Diagnoses included, but were not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-12-22 · tag F0657 — failed to keep the care plan current — patternDevelop 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 interview and record review, the facility failed to ensure resident care plans were revised to reflect current status for 1 of 1 residents reviewed for pressure ulcers and 3 of 5 residents reviewed for unnecessary medications. A resident's pressure ulcer care plan had not been discontinued when the area healed, resident's care plans reflected current use of a discontinued medications, a fall care plan was not revised to include current interventions, and a current diagnosis of shingles and pneumonia that were no longer active (Resident 28, Resident 4, Resident 30, Resident 1)Findings include:1. On 12/21/25 at 9:12 P.M., Resident 1's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus type II, anxiety, and peripheral vascular disease. The most recent quarterly Minimum Data Set (MDS) assessment, dated 11/24/25, indicated Resident 1 was cognitively intact, on an antibiotic, and not taking an anticoagulant. Physician Orders included, but were not limited to, the following: Eliquis 2.5 milligram (mg) tablet (anticoagulant), give one…
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 before2025-12-22 · 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
Based on observation, interview, and record review, the facility failed to ensure a safe, sanitary, and comfortable environment for all residents for 3 of 3 random observations. The resident's oxygen tubing was dragging on the ground, the urinary catheter bag and tubing were dragging on the floor, and clean linens were carried against a staff member's uniform shirt. (Resident 4, Laundry 9, Resident 23)Findings include: 1. On 12/11/25 at 11:57 A.M., Resident 23 was observed propelling himself in his wheelchair down the hallway with a urinary catheter tube dragging under the resident's black shoe and hitting the floor at times. On 12/17/25 at 11:15 A.M., Resident 23 was observed in the common area by the nurse's station in a wheelchair with a urinary catheter bag dragging the floor under the wheelchair. Two nursing staff members walked past the resident, and then the Activity Director wheeled him to the front activity room, continuing to drag the catheter bag on the floor. The resident continued sitting in the activity room with his catheter bag resting on the floor. On 12/18/25 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.
- Potential for harm · D2025-12-22 · 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, interview, and record review, the facility failed to ensure transportation was provided for a resident to get to her neurologist appointments for 1 of 2 residents reviewed for transportation. A resident receiving Botox injections for her Multiple Sclerosis (MS) missed two appointments due to not having transportation. (Resident 9)Finding includes:During an interview on 12/15/25 at 10:44 A.M., Resident 9 indicated her legs hurt bad. Her last neurologist appointment was cancelled by the facility because of transportation issues and now she had to wait until February to get her Botox injection for her MS. On 12/21/25 at 10:28 A.M., Resident 9's clinical record was reviewed. Diagnoses included, but were not limited to, MS, diabetes mellitus type II, and pain in bilateral lower legs. The most recent quarterly Minimum Data Set (MDS) assessment, dated 10/15/25, indicated Resident 9 was cognitively intact and dependent on staff for toileting, showering, and transfers. Current Physician's Orders included, but were not limited to, neurologist appointment with: (provider…
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 · D2025-12-22 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
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 behavior monitoring for 1 of 1 residents reviewed for behavior concerns. A resident's behaviors were not monitored, tracked, or treated leading to an escalation of behaviors. (Resident 2)Finding includes:On 12/17/25 at 11:28 A.M., Resident 2 was observed sitting in a wheelchair in the front activity room participating in an activity. On 12/16/25 at 1:32 P.M., Resident 2's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, depression, and bipolar disorder. The most recent quarterly Minimum Data Set (MDS) assessment, dated 11/18/25, indicated no cognitive impairment and no behaviors. Resident 2's clinical record lacked a physician's order to monitor behaviors. A behavior monitoring care plan, initiated 6/23/23 and last revised 7/17/25, indicated behaviors related to medication changes in 2/2023 as well as a roommate change in 6/2023. A behavior care plan, initiated and last revised 3/26/24, indicated behaviors related to threats of self-harm and suicide. Behavior…
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 before2025-12-22 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 interview and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs of residents for 1 of 5 residents reviewed for unnecessary medications and 1 of 2 closed records reviewed. Medications were not available to be administered as prescribed. (Resident 4, Resident 18)Findings include:1.On 12/16/25 at 1:27 P.M., Resident 4's clinical record was reviewed. Diagnoses included, but were not limited to, status post hip surgery, dementia, anxiety, and depression. The most recent significant change Minimum Data Set (MDS) assessment, dated 11/18/25, indicated a severe cognitive impairment. Physician orders included, but were not limited to:Aspirin 81mg (milligrams), 1 capsule every 3 days, dated 11/14/25. Breo Ellipta inhalation aerosol powder 100-25mcg (micrograms)/act (actuation/puff) 1 inhalation one time a day, dated 11/12/25. Lovenox injection 40mg/0.4ml (milliliters) inject 1 dose one time a day for 28 administrations, dated 11/12/25. Resident 4's medication administration record (MAR) indicated aspirin was not administered on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-22 · tag F0926 — failed to keep the home smoke-free / fire-safe — isolatedHave policies on smoking.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the interview and record review, the facility failed to ensure its smoking policy was implemented for 2 of 2 residents reviewed for smoking. Resident's smoking evaluations were not completed quarterly. (Resident 9, Resident 1)Findings include:1. On 12/21/25 at 9:12 P.M., Resident 1's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus type II, tobacco use, and peripheral vascular disease. The most recent quarterly Minimum Data Set (MDS) assessment, dated 11/24/25, indicated Resident 1 was cognitively intact and dependent on staff for transfers and toileting.Resident 1's current care plans included a Smoking Care Plan, last revised 6/19/23.The last smoking evaluation on Resident 1 was completed on 3/25/25.2. On 12/21/25 at 10:28 A.M., Resident 9's clinical record was reviewed. Diagnoses included, but were not limited to, Multiple Sclerosis, pain in bilateral legs, and tobacco dependence.The most recent quarterly MDS assessment indicated Resident 9 was cognitively intact and dependent on staff for toileting, showers, 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 · Ecited before2025-05-08 · 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, interview, and record review, the facility failed to ensure food was stored and distributed in accordance with professional standards for food service safety during 1 of 1 kitchen observations and failed to complete hand hygiene during meal service. Food was stored in a reach in freezer in the kitchen open to air, undated, and unlabeled. The kitchen equipment and spaces contained dust and debris, and the staff failed to complete hand hygiene after coming in contact with residents while assisting in the dining room. (Resident D, Resident F, Resident G) Findings include: 1. During a kitchen observation on 5/8/25 at 10:55 A.M., a standing reach in freezer contained a box of peas that were open to air, a box of broccoli open to air, a box of cookie dough open to air, an undated bag of pancakes open to air, an unlabeled and undated bag of meat patties, and an unlabeled and undated bag of frozen (what appeared to be) hashbrowns. The kitchen floor under the stove and around the base of the walls had a build up of dust an debris, the ceiling vents and panels contained…
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 before2025-04-01 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 interview and record review, the facility failed to ensure accurate and appropriate medication administration practices were in place for 1 of 3 residents reviewed for pharmaceutical services. A resident received another resident's medications after the administering nurse preset residents' medications prior to the medication pass. (Resident C) Finding includes: On 4/1/25 at 10:45 A.M., an Indiana Department of Health (IDOH) Facility Reportable Incident (FRI) form, dated 3/23/25 at 1:01 P.M., indicated Resident C was given incorrect medications in error. The follow-up FRI, dated 3/28/25, indicated a RN 4 had set up medications prior to administering them and Resident C received the wrong medications. During record review on 4/1/25 at 11:00 A.M., Resident C's diagnoses included but was not limited to, paraplegia, anemia, depression, and seizures. Resident C's care plan included, but was not limited to, resident had an alteration in gastro-intestinal status (initiated 3/19/25) with an intervention that included, administer medications as ordered. Resident had an alteration in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-12-31 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide appetizing and palatable meals for 1 of 1 lunch trays sampled on 1 of 2 halls. Residents complained of cold food temperatures and unappetizing food during meals. (100 hall, Resident J, Resident M, Resident P) Finding includes: During an interview on 12/30/24 at 10:40 A.M., Resident J indicated that she disliked the food at the facility. During an interview on 12/30/24 at 10:55 A.M., Resident M indicated at 1:00 P.M., Resident M indicated that the hot food was often served cold. During a review of facility Resident Council minutes on 12/30/24 at 11:10 A.M., a concern was reported to the facility, dated 12/27/24, that the hot food was cold and colder than last month. Resident Council minutes from 11/29/24 indicated, cold bacon every day, hot food has been cold when it comes to the hall rooms, tired of having the same food . chicken strips and French fries three times in 7 days . During an observation on 12/30/24 at 11:45 A.M., a lunch cart arrived on the 100 hall. At 11:45 A.M., the cart door was opened…
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 15 citations
- Potential for harm · Ecited before2024-12-31 · 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, interview, and record review, the facility failed to ensure food was stored and distributed in accordance with professional standards for food service safety during 1 of 1 kitchen observations. Food was stored in a reach in freezer in the kitchen open to air, and refrigerated and frozen foods were not labeled and dated. Findings include: 1. During a kitchen observation on 12/30/24 at 1:35 P.M., a standing reach in freezer contained a box of frozen vegetables that was not sealed and contained a bag that was open to air of frozen vegetables, a bag of what appeared to be frozen fish fillets were not labeled, and a bag of what appeared to be meatballs were unlabeled. A standing reach in refrigerator contained a an unmarked container of what appeared to be pasta salad. During an interview on 12/30/24 at 1:45 P.M., dietary aide 11 indicated that all food items should be labeled and dated and that unlabeled/undated food must be thrown out. dietary aide 11 proceeded to throw out the unlabeled pasta salad. On 12/31/24 at 12:35 P.M., the Facility Administrator supplied 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 · Dcited before2024-12-31 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure accurate controlled drug records were maintained regarding the dispensing and administration of controlled drugs for 1 of 3 residents reviewed for pharmaceutical services. Controlled substance count sheets did not match the documented administration of controlled drugs during a 30 day review period. (Resident B) Finding includes: During record review on 12/30/24 at 2:15 P.M., Resident B's diagnoses included but were not limited to cerebral infarction, aphasia, fracture of left arm humurus, Resident B's most recent significant change Minimum Data Set (MDS) dated [DATE] indicated the resident had severe cognitive impairment and received opiod medications. Resident B's physician records included, but were not limited to, Norco Oral Tablet 5-325 milligrams (mg) (hydrocodone 5 mg / acetaminophen 325 mg) 1 tablet by mouth two times a day for 7 days (started 12/6/24) and Norco Oral Tablet 5-325 mg 1 tablet by mouth every 4 hours as needed for pain…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-09-20 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation, and record review, the facility failed to provide activities when the Activity Director was out of the building for 6 of 7 residents reviewed for activities (Residents 2, 10, 25, 13, 3, and 12). Findings include: 1. During an interview on 9/16/26 at 11:22 a.m., Resident 2 indicated she liked to play bingo, but nobody was there to do activities and the staff do not work. On 9/17/24 at 1:36 p.m., observed a posted activities calendar in the hallway for the month of September 2024. The posted activities calendar indicated the facility would have the following activities for 9/16/24 at 9:00 a.m. Manic Monday, 10:00 a.m. EZ does it, 11:00 a.m. Devotion, and 2:00 p.m. Fancy Nails. None of the activities were observed to have taken place for 9/16/24. A record review was conducted for Resident 2's on 9/18/24 at 11:16 a.m. The profile indicated the resident diagnoses included, but were not limited to, dementia with unspecified severity, without behavioral disturbance, psychotic (when you perceive or interpret reality in a very different way from people around…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-09-20 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure post dialysis (a medical procedure that removes waste products and excess fluid from the blood when the kidneys are no longer able to function properly) vital signs were documented for 1 of 1 residents reviewed for dialysis (Resident 13), and failed to ensure the administration of medications had been documented in the medication administration records (MAR) for 4 of 12 residents MARs reviewed (Resident 25, 2, 10, and 12). Finding includes: 1. Resident 13's record was reviewed on 9/19/24 at 9:14 a.m. The profile indicated the resident's diagnoses included, but were not limited to, stage 4 chronic kidney disease (a severe stage of kidney disease that occurs when the kidneys are damaged and can't filter waste from the blood as well as they should) and dependence on renal dialysis. An annual Minimum Data Set (MDS) assessment, dated 7/10/24 indicated the resident had no cognitive deficit and received dialysis services. A care plan, dated 4/29/21 and revised on 11/10/22, indicated the resident had end-stage renal disease…
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 before2024-09-20 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a care plan was created for dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with daily life and activities) for 1 of 1 residents reviewed for Preadmission Screening and Resident Review (PASRR) (Resident 2), and failed to ensure a person-center dementia care plan interventions were in place for 1 of 1 resident reviewed for dementia care (Resident 21). Findings include: 1. During an initial pool record review, on 9/17/24 at 9:41 a.m., a Level I PASRR was observed and indicated that Resident 2 required a Level II evaluation. Further review was required to locate the Level II evaluation information. A record review for Resident 2 was conducted on 9/18/24 at 11:16 a.m. The profile indicated the resident diagnoses included, but were not limited to, dementia with unspecified severity, without behavioral disturbance, psychotic (when you perceive or interpret reality in a very different way from people around you) disturbance, mood disturbance (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 · Dcited before2024-09-20 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 interview and record review, the facility failed to ensure care plan meetings were conducted quarterly for 3 of 16 residents reviewed for care plan meetings (Residents 3, 6, and 12). Findings include: 1. During an interview, on 9/17/24 at 9:58 a.m., Resident 3 indicated she could not remember being invited to or attending a care plan meeting recently. She could not recall when the last one was. Resident 3's record was reviewed on 9/17/24 at 1:28 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 7/29/24, indicated the resident had no cognitive impairment. A care plan note, dated 3/26/24 at 10:30 a.m., indicated a care plan meeting was conducted on this day for Resident 3. Resident 3's record lacked documentation of quarterly care plan meetings being conducted in the last 12 months. The resident only had one care plan meeting in the last year. During an interview, on 9/17/24 at 2:27 p.m., the Social Service Director (SSD) indicated she unable to find any additional documentation of quarterly care plan meetings being conducted for Resident 3. She indicated she had not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-20 · 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 record review and interview, the facility failed to ensure there was not a delay in treatment for a resident who had a fall with complaints of pain and discomfort for 1 of 1 resident reviewed for delay in treatment (Resident 18). Finding includes: Review of matrix form (a form with pertinent information regarding residents' condition provided by the facility) on 9/17/24 at 9:09 a.m., indicated Resident 18 had a fall with injury on 7/4/24. Resident 18's record was reviewed on 9/18/24 at 2:19 p.m. The profile indicated the resident's diagnoses included, but were not limited to, fracture of unspecified a part of neck of left femur (a serious injury that occurs when the top of the leg bone breaks below the hip joint), pressure ulcer of unspecified heel (injury to skin and underlying tissue resulting from prolonged pressure on the skin), and unspecified dementia (mild cognitive impairment as yet to be diagnosed as a specific type of dementia). A significant change in status Minimum Data Set (MDS) assessment, dated 7/16/24, indicated the resident had severe cognitive deficit 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 · D2024-09-20 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
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 had adequate pain control during a pressure ulcer dressing change for 1 of 1 reviewed for pain management (Resident 18). Finding includes: On 9/20/24 at 9:55 a.m., Resident 18 was observed sitting in her wheelchair in her room. Registered Nurse (RN) 13 and RN 24 were preparing supplies to complete a dressing change to the resident's wounds on her left heel. RN 13 and RN 24 completed a pressure ulcer dressing change to Resident 18's left heel and surrounding areas on 9/20/24 at 9:55 a.m. to 10:20 a.m. RN 24 removed an old dressing from Resident 18's left heel. After she removed the ace wrap and kerlix (gauze) wrap, she went to the bathroom to wash her hands. RN 13 then sat down and began to cleanse the wounds on the resident's left heel. When the nurse began to clean the wound the resident winced in pain, clenched her jaw and began to move her foot back away from the nurse. The resident indicated it was painful by verbalizing to the nurse that it hurt. The nurse continued with the dressing…
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 · D2024-09-20 · 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 observation, interview, and record review, the facility failed to ensure expired medications were disposed of properly for 1 of 2 medication carts and 1 of 1 medication storage rooms reviewed for medication storage (Resident 3). Findings include: 1. On 9/19/24 at 9:23 a.m., the long hall medication cart contained an opened vial of Fiasp (medication used to lower blood sugar) insulin. The vial contained a handwritten name on it that indicated it was for Resident 3. The vial had an open date of 8/14/24. During an interview, on 9/19/24 at 9:25 a.m., Licensed Practical Nurse (LPN) 14 indicated the Fiasp insulin vial should have been discarded because it is over 30 days old. She indicated she thought the insulin was good for 30 days once opened. Resident 3's record was reviewed on 9/19/24 at 10:17 a.m. The profile indicated the resident's diagnosis included, but were not limited to, diabetes mellitus with hyperglycemia (a condition in which the level of glucose in the blood is higher than normal). A physician order, dated 2/16/24, indicated to administer Fiasp (insulin medication)…
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 before2024-09-20 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure facial hair restraints were used for 2 of 2 kitchen observations. Findings include: During the initial kitchen tour on 9/16/24 at 10:18 a.m., the Dietary Manager (DM) was observed to go into all areas of the kitchen, including the food storage and food preparation areas. He was observed to have facial hair, a visible mustache, without a hair restraint. During a kitchen observation on 9/19/24 at 11:00 a.m., the DM was observed in the food preparation area of the kitchen preparing puree food items. He was observed to have facial hair, a visible mustache, without a hair restraint. During an interview on 9/19/24 at 11:15 a.m., the DM indicated that they had facial hair coverings, but they were located downstairs. Staff were not required to wear facial hair coverings unless they had a full beard. He thought that if they only had a mustache, they were not required to wear facial hair coverings. On 9/19/24 at 11:36 a.m., the DM was observed in the kitchen checking food temperatures in the food preparation area, 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 · Ecited before2023-08-25 · 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 2. On 8/21/23 at 11:02 A.M., the shared bathroom (shared with Resident 18, Resident 26, and Resident 28) between room [ROOM NUMBER] and room [ROOM NUMBER] was observed with two toothbrushes face down in a cup with a tube of toothpaste, all unlabeled. An uncovered emesis basin was observed sitting on the back of the commode, and an uncovered wash basin was observed sitting on the floor under the sink. On 8/25/23 at 11:59 A.M., the same was observed. At that time, Certified Nurse Aide (CNA) 36 indicated the toothbrushes should have been labeled, and was not sure how they should be stored. On 8/22/23 at 11:17 A.M., Resident 18's clinical record was reviewed. Diagnosis included, but were not limited to, anxiety, stroke, and depression. The most recent quarterly Minimum Data Set (MDS) Assessment, dated 6/14/23, indicated no cognitive impairment, and a requirement of extensive assistance of two staff with personal hygiene. On 8/22/23 at 1:16 P.M., Resident 28's clinical record was reviewed. Diagnosis included, but…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-25 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an accurate Minimum Data Set (MDS) assessment was completed for 2 of 5 residents reviewed for unnecessary medications and 1 of 1 residents reviewed for missing personal property. The MDS failed to indicate one resident received 7 days of an antidepressant, one resident received 7 days of a diuretic and had a bed alarm, and one resident had a bed and chair alarm. (Resident 19, Resident 12, Resident 20) Findings include: 1. On 8/22/23 at 1:20 P.M., Resident 19's clinical records were reviewed. She was admitted on [DATE]. Diagnoses included but were not limited to, Type II Diabetes with neuropathy, dependence on dialysis, major depressive disorder. The most current quarterly MDS assessment, dated 6/14/23, indicated Resident 19 was cognitively intact, required limited assistance of one with transfers and toilet use, and supervision with bed mobility and eating. She was on dialysis. The medications listed were insulin for 7 days, anticoagulant for 7…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-25 · 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 properly assist a resident in a [name of lift] lift and prevent falls for 1 of 4 residents reviewed for hospitalizations. A staff member failed to use the handles on the lift which caused the lift to tip over with the resident in the lift pad.(Resident 27) Finding includes: On 8/21/23 11:00 A.M., Resident 27 was observed sitting in the common area with a lift pad under him. On 8/21/23 at 1:37 P.M., Resident 27's clinical record was reviewed. Diagnoses included, but were not limited to, heart failure, hypertension, diabetes mellitus, and hemiplegia. The most recent quarterly Minimum Data Set (MDS) Assessment, dated 8/8/23, indicated Resident 27 was moderately cognitively impaired. The MDS indicated Resident 27 required an extensive assist of 2 staff members for bed mobility, transfers, and toileting. Resident 27's care plan included, but was not limited to, The resident has limited physical mobility r/t [related to] CVA [cerebral vascular accident] left hemiplegia [paralysis of one side of the body], revised…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-25 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure assessments were completed for each resident to evaluate and address nutritional needs on a regular basis for 3 of 3 residents reviewed for nutrition. The Registered Dietitian did not complete evaluations quarterly or with a change of condition. (Resident 18, Resident 27, Resident 28) Findings include: 1. On 8/22/23 at 11:17 A.M., Resident 18's clinical record was reviewed. Diagnosis included, but were not limited to, anxiety, stroke, dysphagia (difficulty swallowing), and depression. The most recent Minimum Data Set (MDS) Assessment, dated 6/14/23, indicated no cognitive impairment, extensive assistance of two staff with bed mobility, transfers and toileting, total dependence of one staff with bathing, and supervision with setup for eating. Resident 18 had not experienced weight loss, and did not have a swallowing disorder. Current physician orders included, but were not limited to, the following: Dietitian to evaluate for nutritional…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-25 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to ensure it was free of a medication error rate of greater than 5 percent (%) for 2 of 6 residents (Residents 11, and Resident 4) observed during medication pass. Two medication errors were observed during twenty-seven opportunities for error in medication administration. This resulted in a medication error rate of 7.41%. Findings include: 1. On 8/23/23 at 7:21 A.M., QMA (Qualified Medication Aide) 2 was observed to administer 1 pill of Potassium Chloride ER 20 meq (milliequivalent) (for heart) to Resident 11. On 8/23/23 at 9:49 A.M., Resident 11's clinical record was reviewed. Diagnoses included, but were not limited to, congestive heart failure, hypertension, and Diabetes Mellitus type II. The most recent admission MDS (Minimum Data Set) Assessment, dated 6/9/23, indicated resident 11 was moderately cognitively impaired and an extensive assist of 2 staff for bed mobility, transfers, and toileting. The current physician's orders included, but was not limited to, the following medication: Potassium Chloride ER…
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
No federal fines in the current CMS record.
Part of a chain
This home belongs to IDE MANAGEMENT GROUP — 10 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.2 | -1.2 vs chain |
| Health inspection | 2 of 5 | 3.2 | -1.2 vs chain |
| Staffing | 2 of 5 | 2.1 | -0.1 vs chain |
| Quality measures | 3 of 5 | 2.9 | +0.1 vs chain |
The other 9 homes this chain runs (chain average 3.2★, 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 / manager | Type | Role | Since |
|---|---|---|---|
| CIBC BANK USA | Organization | 5% OR GREATER MORTGAGE INTEREST | since 11/01/2020 |
| BORNE-BAUMAN, CANDICE | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2019 |
| FLUECKIGER, RUSSELL | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2017 |
| LEHMAN, SCOTT | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 07/14/2020 |
| MACKLIN, LARRY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2017 |
| MCINTIRE, DAVID | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2019 |
| ADAMS COUNTY MEMORIAL HOSPITAL | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2017 |
| OAK VILLAGE NURSING AND REHABILITATION LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2025 |
| MARTIN, THOMAS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| NEESE, KEVIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/15/2025 |
| SANDERS, JODI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| SMITH, SCOTT | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2020 |
| SPRUNGER, KYLE | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2018 |
| WHEELER, DANE | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2017 |
| 200 OAKTOWN PROPCO LLC | Organization | ADP OF THE SNF | since 11/01/2020 |
| BLUE MANAGEMENT SERVICES LLC | Organization | ADP OF THE SNF | since 11/01/2020 |
| CLINICAL CONSULTING SERVICES LLC | Organization | ADP OF THE SNF | since 11/01/2020 |
| FIRST BANK OF BERNE | Organization | ADP OF THE SNF | since 01/01/2020 |
| JSJ HOLDINGS LLC | Organization | ADP OF THE SNF | since 02/25/2026 |
| LME FAMILY HOLDINGS LLC | Organization | ADP OF THE SNF | since 11/01/2020 |
| MIDWEST IN OPCO LLC | Organization | ADP OF THE SNF | since 02/24/2026 |
| SAMARA FAMILY HOLDINGS LLC | Organization | ADP OF THE SNF | since 11/01/2020 |
CMS files one row per role, so the 31 rows in the source record cover these 22 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
11 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.
About 79% 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 $648K paid to related parties — landlords or management companies under common ownership — equal to about 17% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
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 155714. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-22, 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.