No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Transcendent Healthcare Of Owensville

7336 W State Road 165, Owensville, IN 47665 · Non profit - Other · 68 certified beds · (812) 729-7901 Medicare & Medicaid certified

Call the home — (812) 729-7901 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Jun 20242 actual-harm citations$16,036 in federal fines
Insights

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

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $16,036 in federal fines (most recent 2024-04-02)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • about 36% 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.

1/5
CMS overall
1 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 3 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
40 W Fletchall Ave · (812) 874-2228 · Call to confirm hours
Pharmacy
4924 S Maple Tree Dr · (812) 387-4000 · Call to confirm hours
Grocery
IGA8.5 mi
2005 W Broadway · (812) 386-7664 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
8560 W State Road 165 · (812) 724-4001

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 5 of 5
Short-stay residentsrehab / post-hospital 2 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 1 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 rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.2%11.0%15.4%better
Long-stay residents who lose too much weight3.9%5.5%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%1.1%2.0%better
Long-stay residents with depressive symptoms85.2%25.2%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury3.5%3.9%3.3%typical
Long-stay residents whose ability to walk worsened6.7%11.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication42.4%23.5%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.4%95.3%typical
Long-stay residents with pressure ulcers3.8%3.6%4.7%better
Long-stay residents with worsening bladder/bowel control11.8%23.3%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table30.4%13.6%17.1%worse
Short-stay residents who newly got an antipsychotic medication2.4%1.2%1.4%worse
Short-stay residents rehospitalized after admission24.7%22.2%22.6%typical
Short-stay residents with an outpatient ER visit0.0%10.8%12.0%check this — see note marked star below the table
Long-stay hospitalizations per 1,000 resident days2.211.611.67worse
Long-stay outpatient ER visits per 1,000 resident days0.481.441.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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.

10.9%U.S. median 10.7%
Went back to hospital
not reportedno hours filed
Therapy hours / resident / day

Therapy staffing: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.9%CMS range 6.8–18.410.7%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 dischargenot 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 dischargenot 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 dischargenot 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 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 worsened9.1%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.691.02Oct 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

0.47
RN hours/ resident / day
0.46
LPN hours/ resident / day
1.97
Aide hours/ resident / day
2.90
Total nurse hours/ resident / day
0.51
RN hoursweekends
40.5%
Total nursing turnover
37.5%
RN turnover

How full it usually is: this home is certified for 68 beds and averages 53.2 residents a day — about 78% occupied, or roughly 15 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 2.90 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.47 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.97 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 2.54 hrs/resident/day on weekends vs 3.05 on weekdays — 17% thinner on weekends. RN hours go from 0.46 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

8
deficiencies at the latest standard inspection (2025-05-08)
13
at the previous standard inspection (2024-04-02)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

30 citations, most serious first. The 12 most serious are shown; the remaining 18 are one tap away and print in full.

  • Actual harm · G2024-04-02 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure effective services were provided to prevent the development of a facility-acquired stage two pressure injuries for Resident 46 and Resident 9, who were admitted to the facility without pressure injuries, and were identified by the facility upon admission to be at risk to develop pressure injuries. This deficient practice resulted in Resident 46 developing a facility-acquired stage two pressure injury on the coccyx that deteriorated to an unstageable pressure injury with infection and required hospitalization for intravenous antibiotic therapy of wound-based sepsis, and surgical debridement of the facility-acquired unstageable pressure injury to a stage four pressure injury. This deficient practice resulted in Resident 9 developing a facility-acquired stage two pressure injury on the left heel that deteriorated to a stage three pressure injury. Findings include: 1. On 3/27/24 at 1:46 P.M., Resident 46's family member indicated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2024-04-02 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide nutritional care and services including failure to identify significant weight loss, failure to notify the physician of poor intakes, and failure to be reviewed by the Registered Dietician, for 1 of 4 residents reviewed for nutrition (Resident 46). This deficient practice resulted in the resident experiencing a 20% weight loss in 35 days, developing a facility-acquired stage two pressure injury on the 12/28/23 that deteriorated to an infected unstageable pressure injury, and requiring a hospitalization for sepsis, dehydration, and malnutrition. Finding includes: On 3/27/24 at 1:46 P.M., Resident 46's family member indicated they had not been notified by the facility about Resident 46's weight loss. They indicated the resident was hospitalized in January 2024 and they found out about the weight loss then. They indicated that Resident 46 was able to feed herself when she was admitted to the facility but had since declined 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-08 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to maintain infection control practices for 1 of 2 resident's observed for catheter care and during 2 of 3 observations of care. A residents catheter tubing was left dragging the floor following care, staff failed to don (put on) required personal protection equipment (PPE) for a resident in enhanced barrier precautions (EBP), and staff failed to perform hand hygiene between glove changes. (Resident D, Resident K)Findings include:1. During an observation on 1/7/26 at 10:20 A.M., signage hanging outside of Resident D's room indicated a resident in the room required EBP. During an observation on 1/7/25 at 11:25 A.M., Resident D was up in a wheelchair in his room. Resident D's catheter drainage bag was clipped to the wheelchair with the catheter tubing resting on the floor. CNA 4 donned gloves, knelt next to the resident's wheelchair, and emptied the catheter bag into a urinal. CNA 4 closed the catheter bag and disposed of the urine in the resident's restroom. CNA 4 then exited the resident's room with the catheter…

    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 · D2026-01-08 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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 that annual influenza immunizations were offered to 2 of 5 residents reviewed for immunizations. Residents who had given consent to receive the influenza immunization had no record that they had received the immunization or that the immunization was medically contraindicated. (Resident D, Resident G)Findings include: 1. During record review on 1/7/26 at 12:50 P.M., Resident D's immunization consent form, signed and dated 7/16/25, indicated the resident gave consent to receive the influenza immunization.Resident D's immunization history indicated the resident's last influenza immunization was receivedon 10/27/21.Resident D's record contained no indication that the resident had received, refused, or was medically contraindicated to receive the influenza immunization during 2025.2. During record review on 1/7/26 at 10:30 A.M., Resident G's immunization consent form, signed and dated 10/30/25, indicated the resident gave consent to receive the influenza immunization.Resident G's immunization history indicated the…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-05-08 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure the kitchen manager met required qualifications for 1 of 1 dietary manager qualifications reviewed. (Food Services Director) Finding includes: During an interview on 5/5/25 at 9:30 A.M., the Food Services Director (FSD) provided a document that indicated she had been enrolled in a food service manager class from [Program Title] since September 2024 and had not completed it. On 5/7/26 at 10:27 A.M., the employee record for the FSD was reviewed. It indicated she started her role as the FSD on 6/30/24. During an interview on 5/8/25 at 9:11 A.M., the FSD indicated she did not start the management course until September because she did not know which course to be enrolled in. On 5/8/25 at 10:49 A.M., the Regional Consultant Nurse provided a current, non-dated job description for the Director of Food Services that indicated the director was to provide leadership training that includes the administrative and supervisory principles essential of the Food Services Department .

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    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 ensure residents received consistent implementation of interventions to prevent falls for 4 of 4 residents reviewed for accidents related to falls. Fall interventions were observed out of place. (Resident 6, Resident 28, Resident 46, and Resident 45) Findings include: 1. On 5/5/25 at 1:26 P.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, fracture of the lower end of left radius. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 3/13/25, indicated Resident 6 was cognitively intact, required partial to moderate assistance of staff (staff does less than half of the effort) for transferring and toileting, and had one fall with major injury since the prior assessment. A current risk for falls care plan, last revised on 3/5/25, included the following interventions: Anticipate and meet the resident's needs, dated 9/9/19 Be sure the resident's call light is within reach and encourage…

    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 · Ecited before2025-05-08 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure food was stored, labeled, and dated properly in accordance with professional standards for food service for 1 of 2 kitchen observations. (Kitchen) Finding includes: On 5/4/25 at 9:23 A.M., an initial tour of the kitchen was conducted. The following items were observed: In the reach-in freezer: 1 container of butter oil with no open date 4 premade lunches with no preparation date or open date Spice Cabinet: 1 container of oil with no open date 1 container of pumpkin spice with no open date 1 container of ground mustard with no open date 1 container of white pepper with no open date 1 container of spray cooking oil with no open date 1 container of basil with no open date 1 container of garlic powder with no open date 2 containers of parsley flakes with no open date 1 container of thyme with no open date 1 container of mild chili powder with no open date 1 container of onion powder with no open date 1 container of dill weed with no…

    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 · D2025-05-08 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and record review, the facility failed to ensure staff promoted dignity by allowing a resident to use the bathroom when requested for 1 of 1 dining observations. (Resident 18) Finding includes: On 5/4/25 at 12:16 P.M., Resident 18 was observed in the dining room. Resident 18 told Certified Nurse Aide (CNA) 9 she needed to go pee. CNA 9 told Resident 18 she could not go to the bathroom because she had to eat. On 5/6/25 at 8:44 A.M., Resident 18's clinical record was reviewed. Resident 18 was admitted on [DATE]. Diagnoses included, but were not limited to, type 2 diabetes. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 4/8/25, indicated Resident 18 was severely cognitively impaired, required supervision from staff while eating, and substantial assistance (staff does more than half of the work) for toileting, bathing, and transfers. Physician orders included, but were not limited to: Lasix oral tablet (a diuretic medication) - Give 20 mg (milligrams) by mouth one time a day…

    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 · D2025-05-08 · tag F0553 — failed to let residents help plan their care — isolated
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    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 care plan conferences were completed quarterly for 1 of 5 residents reviewed for unnecessary medications (Resident 27) and 1 of 3 residents reviewed for wound care (Resident 14). Findings include: 1. On 5/6/25 at 9:14 A.M., Resident 27's clinical record was reviewed. Resident 27 was admitted on [DATE]. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 3/21/25, indicated Resident 27 was moderately cognitively impaired and required substantial assistance (staff does more than half of the work) for toileting, bathing, and transfers. On 5/6/25 at 9:14 A.M., the clinical record lacked a care plan conference held since 1/15/25. On 5/6/25 at 9:35 A.M., care plan conferences held in 2025 were requested. On 5/7/25 at 10:55 A.M., the Regional Consultant provided a Care Plan Conference Summary, with a completion date 5/6/25 at 12:20 P.M., that indicated 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-08 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents that were self-administering medications were assessed for capability to self-administer medications for 1 of 1 residents observed with medications in their room. (Resident 203) Finding includes: On 5/4/25 at 10:51 A.M., Resident 203 was observed in his recliner with a bottle of Tums on his bedside table. On 5/5/25 at 10:14 A.M., Resident 203 was observed in his recliner with a bottle of Tums on his bedside table. On 5/6/25 at 10:18 A.M., Resident 203's clinical record was reviewed. Diagnoses included, but were not limited to, cellulitis, diabetes mellitus, and obesity. Resident 6 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) Assessment was still in progress and indicated the resident was cognitively intact. Sections regarding medication and functional abilities had not been completed. Physician orders lacked an order for Tums and a self-administration of medication order. The comprehensive…

    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 · D2025-05-08 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure physician orders were followed for wound treatment, labs were obtained prior to antibiotic use, and antibiotics were administered for the duration ordered for 1 of 3 Residents reviewed for wound treatments. (Resident 14) Finding includes: On 5/4/25 at 11:02 A.M., Resident was observed with bilateral feet wrapped with brown bandages over white gauze, no shoes or socks on, and feet directly on the ground. On 5/5/25 at 2:21 P.M., Resident 14's clinical record was reviewed. Resident 14 was admitted on [DATE]. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 2/27/25, indicated Resident 14 was moderately cognitively impaired and required supervision from staff for eating, toileting, bathing, and transfers. Physician orders included, but were not limited to: Cleanse bilateral lower extremities (BLE) with wound cleanser, pat dry, apply oil…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-08 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure infection control practices were followed during wound treatment for 1 of 3 Residents reviewed for wound treatments. (Resident 14) Finding includes: On 5/4/25 at 11:02 A.M., Resident was observed with bilateral feet wrapped with brown bandages over white gauze, no shoes or socks on, and feet directly on the ground. On 5/5/25 at 2:21 P.M., Resident 14's clinical record was reviewed. Resident 14 was admitted on [DATE]. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 2/27/25, indicated Resident 14 was moderately cognitively impaired and required supervision from staff for eating, toileting, bathing, and transfers. Physician orders included, but were not limited to: Cleanse bilateral lower extremities (BLE) with wound cleanser, pat dry, apply oil emulsion to top of foot, wrap with Kerlix (an absorbent gauze) from toes to below knees,…

    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
Show the remaining 18 citations
  • Potential for harm · Dcited before2025-05-08 · tag F0912 — isolated
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide at least 80 square feet (sq ft) per resident in multiple resident occupancy rooms in 1 of 34 rooms reviewed. (room [ROOM NUMBER]) Finding includes: During the entrance conference interview on 5/4/25 at 9:50 A.M., the Administrator in Training (AIT) indicated that room [ROOM NUMBER] required a room variance waiver to have three residents in the room. A waiver had been applied for and not granted. On 5/5/25 at 2:10 P.M., Registered Nurse (RN) 5 provided a document that indicated Rooms that require a variance: room [ROOM NUMBER] measures 70.29 square feet per resident. On 5/8/25 at 9:47 A.M., the Regional Consultant indicated that the facility did not have a room variance policy and followed the federal regulations. 3.1-19(l)(2)(A)

    Environmental Deficiencies · Waiver has been granted
  • Potential for harm · D2024-06-25 · 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 ensure an allegation of abuse was reported to the state agency for 1 of 1 allegations of abuse reviewed. After being made aware of an allegation of abuse the facility failed to report the incident and findings to the state agency. (Resident D) Finding includes: During record review on 6/25/24 at 9:15 A.M., Resident D's diagnoses included, but was not limited to, anxiety, bipolar disorder, dementia with agitation, and senile degeneration of brain. Resident D's most recent Quarterly MDS (Minimum Data Set) assessment, dated 5/8/24, indicated the resident had severe cognitive impairment. Resident D's nurses' progress notes included the following: 6/3/24 at 5:08 A.M. - Resident took self to bathroom, CNA tried to help the resident and resident yelled and punched the CNA several times with fists. Resident has skin tears to bilateral hands, bandaged left hand to help stop bleeding. 6/3/24 at 4:09 P.M. - Residents family notified regarding incident during night shift. Residents alarm began to sound around 5:00 A.M., CNA entered…

    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 · F2024-04-02 · tag F0851 — widespread
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to electronically submit to CMS (Center for Medicare and Medicaid Services) required information regarding direct care staffing for the first Fiscal Quarter from 10/1/23 thru 12/31/23. Finding Includes: During a review of the facility's PBJ (Payroll Based Journal) Staffing Data Report [NAME] Report 1705D on 3/25/24 at 11:15 A.M., the staffing data report included, Failed to Submit Data for the Quarter 10/1/23 thru 12/31/23. During an interview on 3/28/24 at 12:20 P.M., the BOM (business office manager) indicated the payroll based journal information is automatically generated and is the responsibility of outside staff to ensure the information is submitted to CMS timely. On 3/28/24 at 1:24 P.M., the BOM supplied an undated facility policy titled Reporting Direct Care Staffing Information (Payroll-Based Journal). The policy included, .9. Direct care staffing is submitted on the schedule specified by CMS, but no less frequently than quarterly. 10. Staffing information is collected daily and reported for each fiscal quarter no…

    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 · E2024-04-02 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the MDS (Minimum Data Set) Assessment was completed accurately for 4 of 17 residents reviewed for resident assessment. (Resident 46, Resident 22, Resident 5, Resident 45) Findings include: 1. On 3/28/24 at 9:06 A.M., Resident 46 was observed in her room. She appeared to be around 5 feet tall. On 3/28/24 at 10:25 A.M., Resident 46's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease and stage 4 pressure ulcer of sacral region. A Quarterly MDS (Minimum Data Set) Assessment, dated 12/16/23, indicated that Resident 46 had severe cognitive impairment, a formal assessment scale was used that indicated the resident was not at risk for pressure ulcers, and the resident was 74 inches (in) tall. A Significant Change MDS Assessment, dated 1/20/24, indicated Resident 46 had severe cognitive impairment, a formal assessment scale was not used to assess for risk of pressure ulcers, the resident was 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-02 · tag F0657 — failed to keep the care plan current — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care plan conferences were conducted in a timely manner every 3 months and revised with changes for 9 of 12 residents and revised reviewed for care plans. (Resident 8, Resident 4, Resident 34, Resident 46, Resident 49, Resident 11, Resident 5, Resident 45, Resident 4) Findings include: 1. On 3/23/24 at 8:43 A.M., Resident 8's clinical record was reviewed. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, major depressive disorder, and unspecified mood (affective) disorder. The current Quarterly MDS(Minimum Data Set) assessment dated [DATE]. Indicated Resident 8 was mildly cognitively impaired and required extensive assistance with transfer and mobility. Care plan conferences were documented for 11/3/23 but lacked a care plan conference for the next 3 months due in January of 2024. During an interview on 4/2/24 at 11:09 A.M. the MDS coordinator indicated a care conference should have been done in January 2024,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-02 · 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

    Based on observation, interview, and record review, the facility failed to ensure proper handling of tableware and hand hygiene during 1 of 2 observations of dining. Staff handled a resident's coffee mug by placing their thumb on the inside rim of the mug when refilling the mug, and staff failed to perform hand hygiene after coming in contact with residents while providing dining services. (Resident 16, Resident 6, Resident 42, Resident 21) Finding includes: During a dining observation on 3/25/24 at 11:56 A.M., Activities 4 was placing a clothing protector on Resident 16. Activities 4 then pulled Resident 16's hair through the back of the clothing protector, patted the resident's arm, then per Resident 16's request, Activities 4 took the resident's coffee mug and carried it by placing a thumb inside the rim of the mug. Activities 4 filled the mug with coffee and returned it to Resident 16's table. At 12:05 P.M., Activities 4 was changing the television channel with a remote control next to Resident 6 and Resident 42's table. Activities 4 then placed one hand on the shoulder 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-02 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the physician and resident representative of changes in a resident's medical status for 2 of 4 residents reviewed for weight loss. The physician was not notified of a resident's refusal of food and the resident's representative was not notified of significant weight loss or a newly identified pressure injury. (Resident 46, Resident 45) Findings include: 1. On 3/27/24 at 1:46 P.M., Resident 46's Power of Attorney (POA) indicated Resident 46 was hospitalized in January for a pressure ulcer. They indicated they were not told about the pressure ulcer or that the resident had a weight loss until the resident was transferred to the hospital. On 3/28/24 at 10:25 A.M., Resident 46's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease and stage 4 pressure ulcer of sacral region. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 2/3/24, indicated Resident 46 had severe cognitive impairment, had…

    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 · D2024-04-02 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a Resident was provided restorative therapy services to prevent avoidable decline in range of motion and progression of muscle atrophy for 1 of 1 residents reviewed for mobility. (Resident 41) Findings include: On 3/27/24 at 1:21 P.M., Resident 41's clinical record was reviewed. Diagnoses included, but were not limited to, anoxic brain damage, rheumatoid arthritis, and multiple sclerosis. The most recent Quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated Resident 41 had total dependency on 2 staff for transfers, mobility, eating, and toileting, and was unable to assess cognitive function. The MDS Assessment indicated Resident 45 had limitation in range of motion and impairment on both sides of upper and lower extremities but received zero minutes of restorative therapy. Current active physician orders included, but were not limited to: Up with assist and mechanical lift, dated 3/15/24. Turn and reposition…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-02 · 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 interview and record review, the facility failed to provide adequate supervision and assistive devices to prevent falls for 1 or 1 resident reviewed for accidents. Care plans were not revised and new interventions were not implemented following falls. (Resident 4) Finding includes: On 3/27/24 at 12:27 P.M., Resident 4's clinical record was reviewed. Resident 4 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, dementia, chronic instability of knee, and repeated falls. The most recent full Admissions Minimum Data Set (MDS) Assessment, dated 8/23/23, indicated Resident 4 was cognitively intact, required extensive assistance of 1 staff for bed mobility, transfers, and toileting, required total assistance of 1 staff for bathing, had no behaviors, had a fall in the month prior to admission, and had a fall in the 2 to 6 months prior to admission. The most recent Quarterly MDS Assessment, dated 2/16/24, indicated Resident 4 had moderate cognitive impairment, required…

    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 · D2024-04-02 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure 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, interview, and record review, the facility failed to ensure it was free of a medication error rate of greater than 5 percent for 1 of 5 residents (Resident 44) observed during medication pass. Two (2) medication errors were observed during 27 opportunities for error in medication administration. This resulted in a medication error rate of 7.41 percent. Finding includes: During an observation on 3/25/24 at 9:37 A.M., RN 5 was preparing Resident 44's medications, included but were not limited to, Divalproex sodium ER (extended release) 500 mg (milligrams) 1 tablet, and Gabapentin 600 mg 1 tablet. RN 5 then crushed all tablets using a pill crusher and added them to a cup of applesauce. RN 5 then proceeded into Resident 44's room and administered the medications to the resident. During record review on 3/25/24 at 11:00 A.M., Resident 44's physician orders, included but were not limited to, Divalproex sodium ER, 500 mg tablet PO (oral administration), Gabapentin 600 mg tablet PO, and may crush medications as allowed by pharmacy and give together in food of choice…

    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 · D2024-04-02 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview ,and record review, the facility failed to ensure resident records were complete and accurate for 1 of 1 resident reviewed for dental and 1 of 3 residents reviewed for pressure ulcers and nutrition. (Resident 46, Resident 5) Findings include: 1. On 3/28/24 at 10:25 A.M., Resident 46's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease and stage 4 pressure ulcer of sacral region. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 2/3/24, indicated Resident 46 had severe cognitive impairment, did not have any pressure injuries, had a surgical wound, weighed 128 pounds (lbs.), and was 74 inches (in) tall. A review of the census indicated Resident 46 was on hospital leave from 9/15/23 to 10/10/23. A review of the weights and vitals summary indicated the following weights and height: 9/11/23 at 2:56 P.M., Resident measured 61 inches (in) 9/25/23 at 11:30 A.M. Resident 46 weighed 154 lbs. 10/9/23 at 11:30 A.M., Resident 46 weighed 140 lbs. 10/10/23 at 3:56 P.M., Resident 46 measured 74 in. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-02 · tag F0912 — isolated
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide at least 80 square feet (sq ft) per resident in double occupancy rooms and 100 sq ft in single occupancy rooms. This was evidenced in 1 of 34 rooms. (room [ROOM NUMBER]) Finding includes: During the entrance conference interview on 3/25/24 at 9:12 A.M., the Director of Nursing (DON) indicated the facility had a room size waiver for room [ROOM NUMBER] to have 3 residents in the room. On 3/27/24 at 9:22 A.M., room [ROOM NUMBER] was observed with 2 beds with a measurement of 15 feet 10 inches long by 13 feet 6 inches wide, which would result in 71.25 square feet per resident for 3 residents in the room. The room size was verified by Maintenance 5 on 3/27/24 at 12:50 P.M. 3.1-19(l)(2)(A)

    Environmental Deficiencies · Waiver has been granted
  • Potential for harm · D2024-04-02 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident call system was functioning in 3 of 11 room call systems observed. A resident's bathroom call system was not functioning, and a resident's pull cord located on the bathroom call system was broken. ( room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) Finding includes: 1. During an observation on 3/26/24 at 9:15 A.M., Resident 21's restroom call system was observed to not be functioning in room [ROOM NUMBER]. A sign was hanging by Resident 21's restroom door that reminded the resident to call for assistance. On 3/26/24 at 2:30 P.M., RN (Registered Nurse) 5 was informed of Resident 21's restroom call system not functioning. 2. During an interview on 3/27/24 at 12:40 P.M., Maintenance 5 indicated room [ROOM NUMBER]'s call system had been repaired on 3/26/24 and a check had been completed on all resident's rooms call systems the morning of 3/27/24. A call system in room [ROOM NUMBER]'s restroom was also 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-15 · tag F0659 — isolated
    Provide care by qualified persons according to each resident's written plan of care.
    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 residents received care by qualified staff for 3 of 4 diabetic residents reviewed. QMAs (Qualified Medication Aide) documented the administration of routine insulin injections without being certified to administer insulin. (Resident F, Resident G, Resident H) Findings include: 1. During record review on 8/15/23 at 10:45 A.M., Resident F's diagnoses included, but were not limited to; type II diabetes. Resident F's physician orders included, but were not limited to; NovoLog FlexPen (insulin pen) 100 units/mL (milliliter) per sliding scale four times a day (initiated 10/19/21). During a review of Resident F's medication administration record (MAR) from 7/1/23 thru 8/15/23, the resident's routine insulin order (NovoLog FlexPen 100 units/mL per sliding scale four times a day) was documented as administered by QMA 2 on the following dates; 7/1/23, 7/2/23, 7/10/23, 7/11/23, 7/15/23, 7/16/23, 7/19/23, 7/20/23, 7/24/23, 7/25/23, 7/26/23, 7/29/23, 7/30/23, 8/2/23, 8/7/23, 8/8/23, 8/9/23, 8/11/23, 8/12/23, and 8/13/23.…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-08-25 · 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

    Based on observation, interview, and record review, the facility failed to ensure food was stored and handled in accordance with food safety standards to maintain a sanitary environment and prevent foodborne illness during 2 of 2 kitchen observations. Food was stored in containers resting on the floor of the walk-in refrigerator and freezer, an air vent had built up dust, and a kitchen staff member handled food while wearing acrylic nails. Finding includes: During a kitchen observation on 8/22/22 at 9:21 A.M., an air vent above the dishwasher had built up, dark colored, dust. The walk-in freezer contained 3 boxes of frozen vegetables stored on the floor. During a kitchen observation on 8/24/22 at 10:45 A.M., an air vent above the dishwasher had built up, dark colored, dust. The walk in refrigerator contained three crates of milk, chocolate milk, and orange juice, all resting on the floor. The Dietary Manager (DM) was wrapping individual slices of shortbread in plastic wrap while wearing acrylic nails and no gloves. During an interview on 8/25/22 at 9:13 A.M., the DM indicated they…

    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 · Ecited before2022-08-25 · 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 ensure infection control practices were followed for 5 of 7 observations of resident care and 1 of 4 residents observed for medication administration. Gloves were not changed between dirty and clean tasks during incontinence care, handwashing was completed for less than 20 seconds, a nurse failed to wipe the rubber stopper with an alcohol wipe prior to screwing on the needle, and PPE was not put on before entering an isolation room.(Resident 19, Resident 29, Resident 22, Resident 43, Resident 9) Findings include: 1. On 8/24/22 at 9:20 A.M., Certified Nurse Aide (CNA) 11 and CNA 13 was observed performing incontinence care for Resident 19. CNA 11 obtained gloves and resident was rolled to the left, CNA 11 removed the incontinence brief, wiped residents buttocks, disposed of dirty brief, wiped residents buttocks again. Resident 19 was rolled to the right side and CNA 11 grabbed resident's left shoulder and left thigh with the same gloves…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-08-25 · tag F0912 — isolated
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that 1 of 33 resident rooms reviewed met the requirement of 80 square feet per resident. (room [ROOM NUMBER]) Finding includes: On 8/25/22 at 1:15 P.M., room [ROOM NUMBER] (certified for Title 18/19 SNF/NF) was observed. The measurements of room [ROOM NUMBER] were observed to measure 15 feet 10 inches long by 13 feet 6 inches wide. This would result in 71.25 square feet per resident, for 3 residents in the room. On 8/25/22 at 1:10 P.M., a form on [facility] letter head indicated room [ROOM NUMBER] measured 70.29 square feet per resident. On 8/25/22 at 1:34 P.M., the Administrator indicated the facility would like to maintain the ability to have 3 (three) residents in the room. 3.1-19(l)(2)(A)

    Environmental Deficiencies · Waiver has been granted
  • No harm found · C2024-04-02 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    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 at least 8 consecutive hours of registered nurse (RN) coverage during 3 days in a review period from 10/1/23 to 12/31/23. RN coverage was lacking on weekends. Finding includes: During a review of the facility's daily staffing reports on 4/1/24 at 9:10 A.M., the facility lacked 8 consecutive hours of RN coverage on 10/1/23, 10/29/23, and 12/30/23. During an interview on 4/1/24 at 10:37 A.M., the DON (Director of Nursing) indicated being unable to provide any proof that an RN was in the facility on 10/1/23, 10/29/23, and 12/30/23. On 4/2/24 at 3:04 P.M., the Business Office Manager (BOM) supplied an undated facility policy titled Staffing, Sufficient and Competent Nursing. The policy included, Our facility provides sufficient numbers of nursing staff with appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment . 3. A registered nurse provides services at least eight (8) consecutive hours every 24…

    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.

    Nursing and Physician Services 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

$16,036 in federal fines across 2 penalties.

  • $8,018 — penalty dated 2024-04-02
  • $8,018 — penalty dated 2024-04-02

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleSince
HAEHL, PHILLIPIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 01/01/2023
CLAXTON, RYANIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/26/2025
TRANSCENDENT HEALTHCARE, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2015
BRADSHAW PREUSZ, MELINDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2014
BRINK, BRUCEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2007
ALKIRE, KELSEYIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/03/2026
HAPE, KEENANIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/03/2026
NEAL, MICHAELIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/03/2026
O'NIONES, TOMMYIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/21/2026
TRANSCENDENT HEALTHCARE OF BOONVILLE-NORTH REAL ESTATE, LLCOrganizationADP OF THE SNFsince 04/01/2015
TRANSCENDENT HEALTHCARE REHABILITATION SERVICES, LLCOrganizationADP OF THE SNFsince 04/01/2015
GIPSON, SARAIndividualADP OF THE SNFsince 01/14/2023
HALL, EVA SUEIndividualADP OF THE SNFsince 06/17/2014
HAMMOND, MICHAELIndividualADP OF THE SNFsince 12/19/2025
HEDGE, ADRIANIndividualADP OF THE SNFsince 09/01/2020
SWEATT, MEGHANIndividualADP OF THE SNFsince 05/29/2019

CMS files one row per role, so the 22 rows in the source record cover these 16 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.

3 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.

$6.2M
Net patient revenuemost recent cost report
-3.6%
Operating marginrevenue minus expenses
$2.3M
Related-party expense36% of expenses
Who pays — share of resident-days
Medicaid 78%Medicare 16%Other / private 7%

About 78% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.3M paid to related parties — landlords or management companies under common ownership — equal to about 36% 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

$316per resident / day
operating cost
$9,599per month
≈ monthly operating cost
$305per 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 155502. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-08, 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.

What to do next